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oEcxarsrtvT County T/ <br /> 51 °� Industry Services Division <br /> ; ) D 1400 E Washington Ave <br /> $ <br /> P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 3r <br /> PS; / <br /> Madison,WI 53707-7162 -ZI&/ J / <br /> '0n°�Esyro�Ar.S �t //V— <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SYS 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 forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. / �j Sir-,/ T 14 /-r <br /> I. Application Information-Please Print All Information C e d <br /> Property Owner's Name Parcel# <br /> 6e.-"f,e t✓u &e <br /> Property Owner's Mailing Address Property location <br /> f 0-BL7 /7/2 3 Govt.Lot I -t-0, <br /> City,State Zip Code Phone Number /4, - ''/4, Section 12— <br /> /� (circle one) <br /> Sr( rRct t {`%4+ S�'r/ T32 N R tVEorW <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of Trti <br /> Town of d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> FIV <br /> F] New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> 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 El Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 306 Rate(gpdsf) y <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer R b v <br /> Gallons Units o 2 <br /> New Tanks Existing Tanks U iZ t? <br /> Septic or N o in T ��(/ ( L,/ _4 r tv 114- ❑ ❑ ❑ ❑ <br /> Dosing Chamber 1 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /MPRS Number Business Phone Number <br /> frl;/� C✓ "Ls ��- v:� 2- Z.S­rs?i7rr=2-d ��ZC <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> IApproved ElDisapproved Permit Feed+ 00 Date Issued Issuing Agent Signator <br /> ElOwner Given Reason for Denial $ 37J t 42- 3��S <br /> IX.Conditions of Approval/Reasons for Disapprovall�� �}�yAK/ To BP %^�`Loe zoNC, Tf So T�Iw TAvA' <br /> R:s{r t !I/vnr•l .v{r�/ T• /.fit a' A601 e RFF <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ir2 x 11 inches in size <br /> SBD-6398(R03/14) <br />