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„yciar 'y.�� County <br /> Industry Services Division 0rr7C Y_l <br /> 1400 E Washington Ave Stunts Pen t Nul r(to be tilled in by Co.) <br /> P$ r P.O. Box71629 <br /> Madison,WI 5 3 7 07-7 1 62 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this to=to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pennit. 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 infonnation you provide may be used for secondary 6771 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats, <br /> 1. Application Information—Please Print All Information r/6�✓ C or <br /> Property Owner's Name Parcel# G <br /> S- <br /> e7.7oo3 -o,t�000 <br /> Property Owner's Mailing Address n Property Location <br /> tAt r e t r-4 Govt.Lot 2 <br /> City,State Zip Code Phone Number <br /> /., /., Section 3.5' <br /> Inoe/s mN (circle one) <br /> II.Type of Building(check all that apply) Lot# T 1/1 N; R Al E or� <br /> Q I or 2 Family Dwelling—Number of Bedrooms Subdivision Name�7 <br /> Block# V. 3 r IS:5— <br /> ❑Public/Coamnemial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ® Town of S'w/SS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑New System <br /> y ® Replacement System ❑TreatmendHulding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision Change of Plumber <br /> ❑ , El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Phn <br /> Before Expiration Owner :ZIY//r'VISA <br /> TV.Type of POWTS System/Component/Device: Check all that apply) <br /> ® 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(explaut) __ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 1.5'so 6 1 7.s-0 -74 6, 1 9s- 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing"yanks u a +`+ m <br /> 0 <br /> in w U a <br /> Septic or Holding Tank <br /> 1Nl'i �-r.t it <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,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 /> .Rtc(e �6 lef s / <br /> Plumber's Address Street,City,State,Zip Code) <br /> .177Ga �. v 33�' Gv e(s/s.- <br /> VIII.County/Department Use Only <br /> Approved Disapproved <br /> Permit Fee Dale Issued suin' A nt S' ature <br /> ❑ � <br /> ❑ Owner Given Reason for Denial $ 7- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> JUN 3 0 2017 <br /> Al IRA lm% no <br /> Attach to complete plans for the system and submit to the County only on paper not less than B in x 1 t inches in size C;OVN`_ <br /> ZONING •T!V <br /> SBD-6398(R0313) <br />