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County ^� <br /> Safety and Buildings Division ( t.a Pi a <br /> If; 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co <br /> 3 .) <br /> . Is Madison,WI 53707-7162 <br /> 551 251 <br /> Sanitary Permit Application Sate Transaction Number Ll� <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Gal `-'� <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 �70� CD �� <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1 Xm),Stats. <br /> 1. Application Information-Please Print All Information 3 <br /> Property Owner's Name Parcel#07-0(-1.39-/7.23.4 OVCOO-O//OOD <br /> ,} A.1 lrorePov) 0!6 - 31A3 --' •- boD <br /> Property Owner's Mailing Address Property Location O/&-3423-DZ-(o OD <br /> Po /3,0)e V Govt.Lot <br /> City,Slate Zip Code Phone Number <br /> S15114, S6 y,, Section J0 <br /> �Ca✓I dfOL /MN 615_073circle one <br /> 1111..Type of Building(check all that apply) Lot go�V <br /> I?fl or 2 Family Dwel l ing-Number of Bedrooms Is Subdivision Name <br /> $3 PQr6 ol" Block# <br /> $Public/Commercial-Describe Use6A lo,.0 I1^o4nol <br /> [I city of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Town of L trl GO l H <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System <br /> ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Or Other Modification to Existing System(explain) <br /> ord'i fr 4t< 46nK Yeo ,S S• <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 48 5_40 Z Ta( Al;,7 <br /> IV.Type ti S stem/Com onent/Device: Check all that apply) CDa <br /> KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units e a <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber /OO /BO <br /> VII.Responsibility 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 /> /2/G le- /7b &/n,J -71Y-,5',0i(- -1/.S-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a -7706-// 3�s �vebs�Y, wL �Sr3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issum a Signature <br /> ❑ Owner Given Reason for Denial <br /> $ ,t5-.25� z3 Mid 2e/2 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Dlawa,4.f of 5711G lift nab .tell 406"f Dovvi cuesileu, 4 /�Kaa, 5� /-ej� <br /> ConyaG� �o .futS'fit+5 �b1a7'Y. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R- I1/11) <br />