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)/ Count <br /> !r 51 Safety and Buildings Division County <br /> 8s 201 W.Washington Ave., P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 UJ <br /> 558 X413 � <br /> Sanitary Permit Application Stater nNu nq�r 0 <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form m the appropriate govrntmental unit vlq,v11 <br /> is required prior to obtaining a sanitary permit Note:Application forms for sWe-owned POWTS aro submitted to Project Addressif different than nailing address) <br /> the Department of Safety will Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1 Xmj Slats <br /> I. Application Information—Please Print An Informatica 2W7 o//{l/ r <br /> Prope caner' Name Parcel A o7-vW:e 0/S-//-S/5 <br /> /-5 .7//•0/5070 <br /> q 9 �tr30 a -919 50, 0 45"00 <br /> Property Owner Mailing Address_/ �{/. Property Location <br /> 20? !A�/qp vG ,_r/r�h 66W Lot 5- <br /> Ci late <br /> J LL ZippCCode Phone Number '/., Section <br /> fvv/� /� 55bZS- 00 45`7zrrcle one <br /> p <br /> ,IyL Type of Building(check all that apply) Lot d <br /> T N; R E ory <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# 5PO7ie0AW ADD. b f/ w 141 <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑New System y rfReplacemem System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer m New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com onent/Device: Cheek all that apply) <br /> `(. Non-Pressurized In-Ground ❑ Pressurized Io-Ground ❑At-Grade ❑ Mound>24 in ofamorNe soil ❑ Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/freatmeat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sD Dispersal Area Proposed(sf) System Elevation <br /> 69Z 6,e/2 6 42 v <br /> VI.Tank Info Cap try in Taal tl of Manufacturer <br /> Gallons Gallons Unitsv o u R <br /> New Tanks Existing Tanks ^ e` C' 15 u y <br /> v � <br /> 6 r,1 VI H r%1 4 C5 <br /> L <br /> Septic or Holding Tank .w.h.; /WO <br /> Dosing Chamber r��V `^'V <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Print) PI u S Signature MP/MPRS Number Business Phone Number <br /> o( er � wo ILI 1 70 <br /> Plumber's Address(Street,City,State,Zip Cps) <br /> 07MO Int-Kia ni <br /> V fl.County/Department Use Only <br /> Approved ❑Disapproved Permit Free Date Issued Iswin Agent Signature <br /> ❑Owner Given Reason for Denial S �r 771 ' ` L <br /> IX.Conditions of Approval/Reasons for Disapproval J. <br /> Arach to complete ohm for the sssnm and submit an the County only an paper not les than 8 In s l l inches in sin <br /> SBD-6398(R. 11/11) <br />