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Co <br /> 3 * Safety and Buildings Division Af tw,,&— <br /> {?` 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> °;\S IS ' Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Numb <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forth 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.15.04(1)(m),Stats. <br /> I. Application Informattiio�n-Please Print All Information L <br /> Property Owner's a/ Parcel# <br /> Property Owner's M iling Address f Property Location <br /> z5F IV OYI VG Govt.Lot <br /> City,State Zip Code Phone Number 8 <br /> / f`J� �r1 / //�- r /., /<, Section <br /> 7GVA `Jr.pv1 //1N 6'fC75- 6P-91Z— 10Z pp ctrcleor <br /> /' T 7( N; R�Eoro <br /> 11.Type of Building(check all that apply) Lot# <br /> �Ll or 2 Family Dwelling-Number of BedroomsSubdivision Name Pats is t/�! <br /> Block# Ply r - S Plat: <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> r <br /> y Townof 5w rs,� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. p New System ❑Replacement System y ep y ❑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 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaLTreatment Area Information: <br /> Design22FIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7� <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o $ v <br /> New Tanks Existing Tanks v o v 2 y y A <br /> a V in Go w a <br /> Septic or Holding Tank / 1 1/ 2 <br /> Dosing Chamber V'Vf7 <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu s Name(Print) Plumb ignature MP/MPRS Number Business Phone Number <br /> 857g-01-1-115-5601--0Z0Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 7z;?C) �401,'-tnn/ rj1��51�6Y' t,J f' S't8Y <br /> Vill.County/Department Use Only <br /> Approved ❑Disapproved Per?mit Fee O Date Issued Is n gent i <br /> ❑Owner Given Reason for Denial $ J 2� G <br /> IX.Conditions of Approval/Reasons for Disap roval <br /> at{,r1P.0 f %e �P <br /> Qlo� �,14,v S`rouls i MAY 2520 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 rrz:1]inches i <br /> ZONING <br /> SBD-6398(R. 1111 1) <br />