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County <br /> Safety and Buildings Division U(/�✓ <br /> fj 1� lg.,� 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P <br /> F� Madison,WI 53707-7162 QQ p 1 <br /> 656850 V <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wi&Adm.Code,submission of this form W the appropriate governmental unit eq,-i UIG.J �U <br /> is required prior to obtaining a sanitary permit Note:Application farms for sut oa u d POWYS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used or secortdary <br /> iturnoses,in accordance with the Privacy Law,s. 15.04(1 m Stas. y�J <br /> L Application Information-Please Print AB Information /� <br /> P�W Owner's Name Parcel# <br /> /N ell`t� a r 1 a vi ata, Mar" 07-dQ-2 4-25 -Cz CV 30' <br /> Property vner's Mailing Address - Property Location <br /> Zzo lP aN�,v G't�N Solo Kagts Avf. pf6( Gavl.Lnt <br /> C m <br /> City.State Zip Code Phone Nupbrr/e1H SectionI For <br /> Z6 <br /> (�Q /ir0 Nr z 7 ' 33 T -I� N: R / rich;wey.s <br /> IL Type of Building(check all that apply) Lot# �y <br /> C/ <br /> I or 2 Family Dwelling-Number of Bedrooms _ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use CSM Number3 /o97 El Village of <br /> V,?/ Pzo f3 ,Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete lime B if applicable) <br /> A_ lrNew System ❑ Replacement System Treatment/HoldingReplacement Only <br /> Otho Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plurnber ❑Permit Transfer to New LW Previous Permit Number and Date Issued <br /> Before Expiration I Osvuer <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> Non-Pressunzed In-Gromd ❑Presurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitablesoil ❑ 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 Design Soil Application Rate(gpdsf) Dispersal Arca Required(sF) Dispersal�� Proposed(aF) S stem Elev on <br /> W406 S8 93 t <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons GallonsUnits P U o <br /> Nen Tanks E hong Tanks <br /> a`U tan h vi u- V d <br /> Septic or Holding Tank / <br /> Dosing Chamber L'1l <br /> VII.Responsibility StateJmentnt- 1,the undersigned,assume respoludla iry for iastaWtioa of the POWYS shown oa the attached plans. <br /> Plu is Name(Print) Plu Sigramre MP/MPRS Number Business Phone Number <br /> ell eta / S195-1 /$ M <br /> Plumber's Address(Street,City,State,Zip C ) <br /> WeLg,��W:5484 <br /> VIII.Count /De nrtment Use Onl <br /> Permit Fee Date Issued Issuing ignature <br /> Approved ❑ Disapproved S <br /> ❑Owner Given Reason for Denial �•C f{ ?d2 <br /> IX.Conditions of Approval/Reasons for Disapprove <br /> Attach to roadNe alias for the system aid sabma w 1.Caaaty as y oro paper nm Im*on a in a 11 incus in star <br /> SBD-6398(R. 11/11) <br />