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County <br /> /✓ ''` ;: Safety and Buildings Division 8eAprf-e <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> S Sanitary Permit Number(to be filled in by Co,) <br /> ` P$ z Madison,WI 53707-7162 <br /> Sanitary Permit Application Slate Transaction Numbeyrn <br /> In accordance with SPS 383.21(2).W is.Adm.Code,submission of this form to the appropriate governmental unit a .) <br /> is required prior to obtaining a sanitary permit. Noce:Application forms for state-owned POWTS are submitted to Project Address(ifditYerent than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary t 8533 <br /> pur2oses in accordance with the Privacy Law,s. 15.04(1 Nm),Staff. R p <br /> 1. Application Information-Please Print All Information 13f�'Ca7 .S4- G/C <br /> Property Owner's Name Parcel H p 7-09 8,2240 4y s <br /> O enhvnrr a C6-Op9- o/`/DoV <br /> Property Owners Mailing dres's Property Location <br /> 6W, A4T zF Str�lpryr rl <br /> 1S fir Gh,eQ L i h� Govt Lots 3lit IL <br /> City,State Zip Code Phone Number (8 <br /> 4. SZSI Section <br /> A/ t"sa4k fn/V SS'997 (circle one) <br /> T <br /> H.Type of Building(check all that apply)I Lot N 4•D N; R «f E or <br /> I or 2 Family Del l ing-Number of Bedrooms *#4A Subdivision Name <br /> Block q <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> El State Owned-Describe Use CSM Number ❑ Village of <br /> Vol 11 P T I�To.of fGa <br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicable) oollo <br /> — <br /> 'ANew System <br /> ,� ❑ Replacement System ❑ Trea[menVHoldine Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. E Permit Renewal E Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> �I,V..Type of POWTS System/Cam onent/Device: Check all that apply) <br /> 61 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil E Mound<24 inofsuitable soil <br /> E Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment.area Information: <br /> Design Flow(Vd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 300 . r7 4Y.A9 via -71• s� <br /> VI.Tank Info Capacity in Total is of Manufacturer <br /> Gallons Gallons Units <br /> 4 v <br /> New Tanks Esisdna TanU <br /> Septic or Holding Tank <br /> Dosine 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 /> 12,1414 /�/* k thr .�,.., /„Isar1 T1s-86x- vis? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -7-7'0 //,. y 3S Websf.e. &✓T S'lt39 J <br /> V[ .County/Department I se Only <br /> Approved 0 Disapproved I Permit Fee Date Issued Issuing Aa io ture <br /> $ ,yam _ _ <br /> 11 Owner Given Reason for Denial If' 2J`-V— <br /> IS.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 VS z[I inches in size <br /> SBD-6398(R. 11/11) <br />