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�. County' 1 <br /> Safety and Buildings Division t,Nn <br /> ; a �'. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1sPS' � Madison,WI 53707-7162 <br /> 'V SS 3 <br /> Sanitary Permit Application State= cuonN°er U <br /> In accordance with SPS 383.21(2),W'is.Adm.Code,submission ofthis form to the appropriate governmental unit � (C,0 <br /> is required prior to obtaining a sanitary permit. Note.Application forms for state-owned POWTS are submitted to Project Address(ifdifferent 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 xm),Stats. 7�7 <br /> t/O lief U• <br /> 1. Application Information—Please Print All Information 11 <br /> Property Owner's Name Parcel# <br /> 1"A✓tle /`0S-1C.^ T j5 /� 05-60dl -0/4' 000 <br /> Property Owner's Mailing Address Property Location Ly,WO 'u2u•y (•o)i <br /> 9 ?e r,ttA a 4,e Govt. Lot A <br /> City.State Zip Code Phone Number A %- Section <br /> St PeeLw If /n AlSj�/Op (circle one) <br /> 11.Type of Building T �/0 N, R /�_E orb <br /> �y yp g(check all that apply) Lot# <br /> ip l or 2 Family Dwelling-Number of Bedrooms oil Subdivision Name <br /> Block is <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of at L-lt"'Ve <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> `,- ❑ 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 <br /> IV.Type of POVVTS S stem/Com onent/Device: Check all that a Iv <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inof suitable soil ❑ Mound s 24 inofsuitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersab Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 00 7 tid 5 43.E �o• s- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> u <br /> Gallons Gallons Units ^ ' y <br /> v j <br /> New Tanks <br /> Existing Tanks u c <br /> Septic or Holding Tank /�s-O ��� / �hT i('{-✓a`;0/ x <br /> Dosing Chamber <br /> VII. Responsib ility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street, rty,Soate,Zip Code) <br /> 3� GI/ ��s�ti� �✓ r S `�`8�i <br /> V111.Countv/De artment Use Onlv <br /> Approved ❑ Disapproved Permit Fee <br /> Date Issued Issuing Ag gnature <br /> El Owner Given Reason for Denial $32 J is <br /> 1\.Conditions of Approval/Reasons for Disapproval mgiE nn <br /> AUG <br /> .attach to complete plans for rhe system and submit to the County only on paper not less than 8 trz l' es in size <br /> SURNETTCOUNTy <br /> SBD-6398(R. 11/11) ZONING <br />