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U ► /I/ M <br /> ON COMPUTER/SCANNED <br /> a Safety and Buildings Division <br /> Ds <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> � Madison,WI 53707-7162 S _t J4O� <br /> Sanitary Permit Application State Transaction Number ' <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (0V w/,-) R-e V,4k t✓ <br /> is required prior to obtaining a sanitary permit. Note:Application fortes 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),Slats. Q-74 �t /� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name eel# ��l <br /> P Wear 1 r-A-q0-15 -20-If-O3 -Qoo- <br /> Property Owner's Mailing Address Property Location <br /> W f 1,7&g0 r ye_ Govt.Lot <br /> Ci State Zip Code Phone Number 5E _y, �.. y,, Section V <br /> rcicone) <br /> II.Type of Building(check all that apply) Lot# T N; R E or W <br /> Yl 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 /> Town of T4C dN/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ❑ Replacement System Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ElPermit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date sued <br /> Before Expiration Owner <br /> IV.Type of POWTS S•stem/Com onent/Device: (Check all that apply) o '� <br /> X 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A placation Rate(gpdsf) Dispersal Area Requited(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3c� y8'o 706 f#. 2 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o B S 2 <br /> New Tanks Existing Tanks <br /> in ,, i U <br /> Septic or Holding Tank O A it <br /> Dosing Chamber V -Y <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POW'fS shown on the attached plans. <br /> Plum Name(Print // Plumbe ' �naturc MP/1v1PRS Number Business Phone Number <br /> 55�o��q c� )� ��/9s'y 7is S6�o w Z <br /> P umber's Address(Street,City,State,Zip Code) <br /> �/ U•1 e�s,4�- (i 5-70 <br /> VIII.Court e artment Use Only <br /> (� Approved El <br /> Permit Fee Date Issued Issuing Agent Signature <br /> " s 37s.. °% g- �a-ice <br /> ❑ <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> AUG 10 2015 UU <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 v2 1ftWi z <br /> OUNTY <br /> ZONING <br /> SBD-6398(R. 11/11) <br />