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flTAI <br /> Ve T'�T Count _ <br /> Safety and Buildings Division y Ll 1^AJ G <br /> N/A 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> r Madison,WI 53707-7162 <br /> 55/,?�i 2 <br /> 1`essxtN A�� <br /> Sanitary Permit Application State Transaction <br /> In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmentalunit is required prior m obtaining a sanitary permit. Noce: Application forms for state-owned POWTS are Project Addresnt than mailing address) <br /> submitted to the Department of Safety and Professional Servies. Personal information you provide may be used <br /> for secondar u ses in accordance with the Privac Law, s. 15.04(1)(m),Stats. $38S KI. A lication Information-Please Print All Information <br /> Property Owner's Name Parcel# d _7 36 .-Z Vo i7aS <br /> ao 0ood <br /> Pr perry owner's Ma iling Address Property Location <br /> t � <br /> r° Govt. Lot�_ <br /> City,State Zip Code Phone Number 34,Section 1.2 S. <br /> (circle o e) <br /> II, Type of Building(check all that apply) Lot# T N; R_17 E oz <br /> Y::1-or 2 Family Dwelling-Number of Bedrooms a Subdivision Name <br /> 0 Public/Commercial-Describe Use Block# _ <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Num ber 0 Village of <br /> / <br /> Cj own of <br /> III. Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A' V�,New S stem <br /> y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer m New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> .WNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound > 24 in.of suitable soil 0 Mound < 24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Desi n Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed(so System Elevation <br /> ©o 15 /200 ,24D 953.00 i 950,r)D <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Nc <br /> New Tanks <br /> Existing Tanks <br /> g w 2 U <br /> Septic or lielCiug_1'ank <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prin t) Plumber's Signa rare MP/MPRs Number Business Phone Number <br /> Plumber's Address(Street ,City, State,Zip Code) <br /> ,-� -n;_/-/ e ---) w `/87 <br /> VIII. Count /De artment Use Onl <br /> Approved 0 Disapproved Perm2it Fee Date Issued Issuing n[S)gnarare <br /> ❑ Owner Given Reason for Denial S 3Z5� fGjUfle 70& <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> ceuts)o� -r �n�ld /x.a,& q 5�(� .2(_)Ig 71 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ra x 11 inches in size <br /> SBD-6398(R. 11/11) <br />