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/�y5yi1 Countya? <br /> ;s Safety and Buildings Division "YN f W <br /> US. 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> 1 PS' Madison,WI 53707-7162 <br /> 5 04 <br /> Sanitary Permit A„plication Stale Transaction Number <br /> In accordance with SPS 383 21(2).Wis.Adm.Code,submission of this form to the appropriate governmental unit -Wq 1 <br /> is required prior to obtaining a sanitary penri[. 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. 15.04(I pm).Stats. 3/S8 K.I Sl✓ewv Al <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# ,9 /N•/rj-3- <br /> �n 07-D QF-a-yO• <br /> /11Arx4a0Aj W 05-003 -04loco OSb03_ VZ= <br /> Property Owner's Mailing Address Property Location <br /> 75-/ti 4f,,A St N• Govt Lot 3 <br /> City,State Zip Code Phone Number 7.. 'G, Section /9 <br /> Oa (Cda/C <br /> 1-4 Al I3s1a f (circle one) <br /> T WN; R /�/ E o <br /> ..1 & <br /> 11.Type of Building(check all that apply) ? Lot# <br /> I ort Family Dwelling-Number of Bedrooms ,2+ 3 Subdivision Name <br /> Block# <br /> ❑ Pubhc/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village ofp� SLOT' <br /> Town of , <br /> Vol. 11 Nit 135 y <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) 028-4//9_ Ole•,300 i <br /> 7�7 -NeSystem ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued <br /> ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> [%.Type of PONb'TS Svstem/Com onent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ?Mound>24 inofsuilable soil ❑ Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpcist) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> r!s o 7 ys'o soy `l7 30 <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = o <br /> y <br /> a P V <br /> New Tanks Existing Tanks u � y � y s <br /> 0 <br /> G rJ <br /> Septic or Holding Tank eS0 /OOO <br /> Dosing Chamber �BD 6vo <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW'TS shown on the attached plans. <br /> Plumber Name(Print) Plumber's SianalureN1PiMPRS Number Business Phone Number <br /> /CiG/c /-ro �iint / dna SBS/ ?/S`&G` c/is7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -7700 //.,..z, .5_'1a893 <br /> N'III.Countv/De artment L'se Only <br /> ❑1 Approved ❑ Disapproved Permit <br /> rFee <br /> C D�agte Issued q Issuing ignature <br /> El Owner Given Reason for Denial $ 3 f f��� zs c. SUMP. /Z, <br /> IS.Conditions of Approval/Reasons for Disapproval n <br /> Tt 6vtif.4 S/dt (a4 Aga 4 /rooa(T�rs) IS mt l�flrc aC b be lur�tailrtir <br /> ;loop( p/d..:, p16, 3•SIJ..r.'( <br /> 4--A a o� E.a. FACIA fort Q�ufnttCCcr.�y dv6ao( /v9- /g Zoo B. 61kLk4r5�u LzRt: 99500 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S In s 11 inches in size <br /> SBD-6398(R. 11/11) <br />