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dsf'�`r County <br /> q Safety and Buildings Division 4 r.) e_ <br /> ' p 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> 9'�sTfprar.1 SSi289 <br /> Sanitary Permit Application State Trana9tion Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safely and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. / <br /> I. Application Information—Please Print All Information <br /> Property Owner's erne Parcel H 6 7 aO 6-oZ 3 S-/-7—//-/-' <br /> o` o 3—coo— o//ao,3 <br /> Property Owner's Mailing Address Property Location <br /> _30,p <br /> 0 p y I-U e _57 <br /> o6G-2(II-ol Seo <br /> Govt.Lot / <br /> City,State <br /> nn Zip Code Phone Number y, p/C y4 Section I <br /> r "e riG W .7 YS",� '7 (circle one) <br /> T N; R l 7 E orn <br /> II.Type of Building(check all that apply) Lot n <br /> or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �- <br /> Block N <br /> ❑Public/Commercial-DescribeUse - ' <br /> ❑City of <br /> '— <br /> El State Number State Owned-Describe Use ❑ Village of <br /> P=Townof oO /1-/t-'I eJ5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. $-New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal 11 Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onentlDevice: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sopersal Area Proposed(so System Elevation <br /> 3 6 <br /> YDis <br /> S-6 <br /> 96.5 <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> a U in v, i+. C7 44 <br /> Septic or Holding Taak /•OO /O40 1 G Cyt.C- <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> -(Print) <br /> Plumber's Address(Street,City,State,Zip Code) <br /> r�o N S/ //_ <br /> VIII. ount /De artment Use Onl <br /> Permit Fee Date Issued Issuing gent Signature <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial $3aS M <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size <br /> SBD-6398(R. 11/I1) <br />