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- -- <br /> ' /.4rvjaDt <br /> r-- <br /> „N..... Industry Services Division County .. <br /> 1400 E Washington Ave 5 utKifETT <br /> PI • ‘4: <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t$1 ... $1, ,:: <br /> I '‘. ‘ .2 ; ,' Madison,W1 53707-7162 5.RN-.24) -16 <br /> A.,....._' . c <br /> •\1...4... ...5- c'i 7--2.0-/4// <br /> State Ti ' Number <br /> Sanitary Permit Application <br /> ' I (028P8 <br /> hi accordance with SPS 3k3.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit i <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Prp3bet Address(if different than mailing address) <br /> the Department of Safety and Professional Services.A.taortal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> oq414 M(AleatcYA Ntvk RP, <br /> 1..._1212plication Information-Please Print Ali Information <br /> Property Owner's Name <br /> Parcel# 0 7- 03 2.-2-4f/-Av.-34., - 2 <br /> _-___,.,., 5-:;7:,,c;:,/3-K. cr -coo -01/60 tr 3334 <br /> Property Owner's Mailing Address Property Location <br /> L2.-(Y-1.Z1 'ECI-C.)R i 434;6-Av---, IN). <br /> Govt.Lot - <br /> City,State Zip Code Phone Number ma- v.„ Ail( %, Section 36 <br /> .. .c,f_r:_VI t_t_L-., MA,, 'i i..1_33 (circle ozot ) <br /> T 411 N; R <br /> II.Type of Building(cheek all that apply) Lot 0 <br /> z / Subd ivision Name <br /> Yifl or 2 Family Dwelling-Number of Bedrooms <br /> Block# Ailt <br /> 0 PublidCommercial-Describe Use of <br /> i z 0 Village of <br /> 0 State Owned-Describe Use CSM Number lig 7 <br /> terou„f 5- L 3 S <br /> V 1, P 1 z0 <br /> DI.Type of Permit: (Check only one boa on Awe A. Complete line 13 if applicable) <br /> A. ANew System 0 Replacement System 0 Treatment/Bolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 0. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List.Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1IV.Type of POWTS SystemiCouspoisent/Deview (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurised In-Grotmd 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 34 <br /> 0 Bolding Tank ) .Other Dispnbal Component(explain) ii i-Trik 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatassid Area Information: <br /> Design Flow(gpd) Design Soil Application Rateigpdsf) Dispersal Area Required(at) Dispersal Area Proposed(at) 1 System IlevaW <br /> 300 r),1 ,--;',7s,5.s.• ./ 1j ; <br /> VI.Task Info 1 Capacity in Total #of Manufacturer <br /> . ..t. <br /> Gallons Gallons Units ti 13-a u <br /> .0 <br /> New Tanks Existing Tucks i § 1 g -1 1] TT4 <br /> it o iE V rfi ir.(.7 is: <br /> Septic or-Houtriteic /7 ,0 <br /> :(': i -E.5_-A.' X • i <br /> Dose - <br /> VII.Responsibility Statement-I,the tuidersim' sl,ass.,,,. -. , ., lily Jai installation of the POW shown on the attached plans. <br /> Plumber's Name(Print) Plumber'.Vgnature ! Maltiind.Number 1 Business Phone Number <br /> (10 AY .1-.Z4eK•SCA:f -11' 4/ I 5 4 331 I 715-S4-.4-5)1YY <br /> rPlumber's Address(Street,City,State,Zip Code) <br /> q3Cb ,94.4eK BRC19K 12b, tt,IFISSTOq L/61:1-' SI g43 <br /> ) <br /> VIII.CovelyrJepartniest Use Only <br /> ijatirpprovei 0 Disappraved Permit Fee Date '1uing A:4..1 Sit.... / <br /> 0 Ownet Given Reason for Denial i -f So 2ozb AOP ....grairi <br /> IX.Conditions of Approval/Reasons for Disapproval IIIP' <br /> .. sistowt. oevediesi mast ist of of 040"),C. 91.5 <br /> Or . <br /> -1)4 0.64d 6 WALa kot Web <br /> lift 4 cover reiptired Nev dieyattfrirtt cett <br /> Meads to compleie pions far die system and submit to the Comedy oafs on paper sot less than A . I 7.'--7. 1 ., L <br /> I v E <br /> SBD-6398(IZ.08/14) JUL 29 2020 <br /> :urnett County <br /> Land Services Department <br />