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Cozen <br /> Safety and Buildings Division T N <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be fitted in by Co.) <br /> Madison,WI 53707-7162 <br /> ��"'mtwsav <br /> 5S)a- W <br /> Sanitary Permit Application State Tran ction/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 mmts for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety end Professional Servies. Personal information you provide may be used for secondary <br /> u oses in accordance with the Privac Law,s.15.04 ] m,Stats. D <br /> I. Application Information-Please Print All Information 28 9 9 3 Voyage( �D <br /> Properly Owner's Name // Parcel# p 7- ,. <br /> Nber� C�r3g� oS- do - ol 000 <br /> Property Owner's Mailing Address Property Location <br /> O �} Govt.Lot <br /> City,State Zip Code Phone Number <br /> 'n\ �/ '/4, '/4, Section�- <br /> N f�N 6�{ r to _r � 11 O - s a/ (circle one <br /> rII.Type of Build' g(check all that apply) Lot# T 0 N; R /.�E or VV✓ <br /> tp r or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use C7N=7bc�r ❑Village of <br /> p 9 6 ❑Town of_ \ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System �Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner '0bfab(,0 6-1cqw <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Ion-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suita a soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sl) System Elevation <br /> 7 6<13 6 :5-o <br /> 9y�3- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks 8 vp <br /> Septic or AaWiagSydc /000 r .r IO O <br /> Dosing Chamber / S O <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)p Plumber's Signature MP/MPRS Number Business Phone Number <br /> ► W/rf 6 ,n �o zz7�9/ �y9 70286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ElApproved ElDisapproved Permit Fee Date Issued �", Issuing Signature <br /> '15ElOwner Given Reason for Denial $`-' a ���'" <br /> 00 <br /> IX.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 IR 1 h'Mze <br /> SBD-6398(R. 11/I1) BUR Z� NGUNTY <br />