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;r oe ty <br /> Safety and Buildings Division Coun�L4/ <br /> a 4 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled to b Co. <br /> >�� a Madison,WI 53707-7162 Y )� <br /> I°"�` 55882, <br /> Sanitary Permit Application State Tran nNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than i in address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> u oses in accordance with the Priv Law,s.15.04 1 m,Stats. <br /> I. A lication Information-Please Print All Information !(Sj 7 9d 7 S/4 �� <br /> Property Owner's Name <br /> ( Parcel# O -0/ -�•aiyd./ .�,5-.3- <br /> Property Owner'sMailing Andress " 68D- 0-5--00 - O S oc:,0 <br /> C/ <br /> 6 V /�j - / Property Location <br /> City, tato 'j Govt.Lott_ <br /> /. f Zip Code Phone Number 6i7 'e/" /0pl SS D /• Y., Section <br /> cXtrcle one <br /> II.Type of Building(check all that apply) Lot# T �le N; R E <br /> *or 2 Family Dwelling-Number of Bedrooms-- Subdivision Name <br /> ❑Public/Commercial-Describe Use Block <br /> ❑City of <br /> ❑State Owned-Describe Use ^ CSM Number ❑Village of <br /> / v W'own of n:AC:_ Sa'10 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ _ _ <br /> A. ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit in <br /> ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration 8 ❑Permit Transfer to New <br /> Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply)— <br /> Non-Pressurized <br /> INon-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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> 0 Odea <br /> I.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks <br /> Exisliag Tanks 2 <br /> a,./U in rn w0 a <br /> ftpii& r Holding Tank 1333 <br /> 1J 3 O 2o43 c+� .5 K/k(.d CNS WVC7.51 !� <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 /> 4(X-14JEL ku1�117o M /t/ex� zZ769/ 7-78 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Q 0 X s—/ S /i- e.—J --r 5- !�p <br /> VIII.County/De artment Use 0nl <br /> (Approved ❑Disapproved Permit Fee Date Issued Issuing Agen ture <br /> ❑ Owner Given Reason for Denial <br /> 75 13A-,. <br /> DC.Conditions of Approval/Reasons for Disapproval <br /> s�� kr mac. Id�(d.�'� �aatrc t„sbfl�6aw 'ts n�� lncltc�.( to /c. wrELfa,, <br /> v�k¢ C/wot/tlauo of f(arfh Sae( L-d4e_ tm tke rJAA ap <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R. 11/I1) <br />