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7+— <br /> County- <br /> 4- <br /> Industry Services Division — <br /> 3 ' 0 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> $P 5 1`I P.O. Box 7162 <br /> h � �7� <br /> *i Madison,WI 53707-7162 r _ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note*Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> �l0�ct ter/ L%Ji-t/G o?oaff 3. VON o? -S'oSoe3Of30 j0 <br /> Property Ow/ner's Mailing Address Property Location: <br /> c <br /> 1Lf 1 �"l ln/r51 PT 2 0 Govt.Lot 14-5- <br /> t-3 ^ <br /> ,$tate Zip Code Phone Number 'A y, Section Q J <br /> OOd-ca- Q-,t— .5`(8(7 (circleone <br /> IL Type of Building(check all that apply) Lot# T Y c7 N; R1_1 E or� <br /> �/ PP Y) / <br /> 0( for 2 Family Dwelling-Number of Bedrooms _ l Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-DescribeUse <br /> ❑ City of <br /> ❑ State Owned-Describe Use CSMNumber ❑ Village of <br /> V ;,( /1 R Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modifications to Existing System(explain) <br /> B. <br /> El Permit Renewal ❑ Permit Revision ❑Change ofPlumber ❑Permit Transfer toNew List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> EFF FILTER MFG: LEACHING CHAMBER MFG: <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> DI-Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ Al-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> El Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VL Tank info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v v <br /> New Tacks Fxisting Tanks <br /> P4 U (n 6,; iz 0 P. <br /> Septic or Holding Tank /® V/ 6 1000 <br /> QO0 !t r-r <br /> Dosing Chamber ! <br /> VH.Responsibility Statement-1,the undersigned,assn responsibilityin installation of the POWTS n on the attached plans. <br /> Plumber's Name(Print) Plumber' ign RS Number Business Phone Number <br /> nl burr as 3 S`v W ?/-T- Y16 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Al 51el 6 T-y Yfw va,frw- <br /> VIII.Court 'mertment Use 0 <br /> pprovD Disapproved <br /> Date Issued [ssui g A nt Si afore <br /> Aed ?7�S DB <br /> DOwner Given Reason for Denial ,7 •f �� 'a7-r/� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and sabmit to the Comfy only m paper not less than 8 t2 a It inches in Nice <br /> SBD-6398(R0313) <br />