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:ate•:•. <br /> Safety and Buildings Division d <br /> <X ; D S p'l 201 W.Washington Ave.,P.O.Box 7162 Sanitary Pitt Number(to be filled in by Co.) <br /> PS _J Madison,WI 53707 7 7�162 L f�/ ! q3 <br /> *n' <br /> _ % TJ <br /> .. y State Tmraaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 333.21(2),Wis.Adm.Code,submission of this form to die 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.I5.04(1)Im),Scats. <br /> L Application Information-Please Print Ali information5111 <br /> Property Owner's Nume6 Parcel# <br /> 0� I� <br /> Property Owner's Mailing Address Property Location <br /> /t� ,�-/A <br /> Gout.Lot <br /> City, <br /> IyState <br /> �p Zap Code LPho7neN�jumber '-`�,. V., y,, Section ^ S <br /> U.Type of Building(check all that apply) � Lot# <br /> qCW <br /> I 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> n <br /> #11 I%Town of �4F� <br /> III.Type of Permit: (Cheek only one box on line A. Complete linefB if applicable) <br /> G <br /> A" ❑New System V Replacement System ❑TreatmentfHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 6• ❑Permit Renewal Q Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit rraissfer ro New 1 <br /> Before Expiration Owner yi <br /> s n s 3-3/-87 <br /> IV.Type of POWTS S stem/Com nestUDevice: (Check all that apply) <br /> WNon-Pressurized(n-Ground ❑Pressurized[,-Ground ❑At-Grade ❑ Mound>_24 in.ofsuitable soil ❑Mound<24 in.ofsuitablesoil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arco Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufactmcr <br /> Gallons Gallons Units o'� <br /> New Tanks Existing Tanta: c e o <br /> t�7d c U fn & rn i_C7 is <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached platys <br /> Plum s Name(Print) Plumber's S' hoc MPiMPRS Number Business Phone Number <br /> roy� D�� d& 8Sy`�S 7i5-SG6-oZo z_ <br /> Plumber's Address(Street,City,State,Zip Code)/) f <br /> Z 7Z20 nG (/► 9514" t.i <br /> Vill.County/Department Use Only <br /> Approvred Pemtit Fee Date Issued Issuing Agent Sign <br /> ❑Disapproved <br /> ❑Owner Given Reason for Denial <br /> IV-Conditions of Approval/Reasons for Disapproval / <br /> levrpC 44;. /,t;,. 42 "or .ylort o?C Gov-Pr aver <br /> Attach to complete plans For the system and submit to the County only on paper not lea than 5/R ill Inches In she <br /> SBD-6398(R.I1/11) <br />