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OORlfrterCe.Wl.gov Safety and Buildings Division County 1 <br /> 201 W.Washington Ave.,P.O.Box 7162 G f r-it,e I <br /> 1Sc ns!n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) ( \ <br /> s3z/ 05 w <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental J 8 65 83 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I (m),Stats. <br /> I. Application Information—Please Print All Information <br /> Prop Own 's N Parcel#O 4'2-- S O � � <br /> '1 ti C <br /> Property/wnQer's Mailing Addres f Property Location r . 1 ,t 0 <br /> l 6 / o 60 Q Govt.Lot S Z p T W it)Ac- <br /> C' State Zip Code Phone Number C` y., t p�yy Section 3 <br /> �Y-"6v f W t Sq91(0 _ 6 Z N/ (circle one) <br /> H.7Type of Building(ch k all that apply) Lot# Tjr N; R ( g- (,�f <br /> 17CI1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> /T, Block# <br /> ❑Public/Commerci d—Describe Use <br /> City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of f r <br /> ® Town of Woo t ✓-el/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ `' <br /> A. New System Li Replacement Li Treatment/Holding Tank Replacement Only Lj Other Modification to Existing System(explain) <br /> System <br /> —NJB. Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner ,t�Q 4 � p r n- 07 <br /> Expiration "7" �j .J— / <br /> IV.T e of POWTS S stem/Com onent/Device: Check all that a 1 <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> DesiVjIow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Ar <br /> /ea <br /> / <br /> Pr <br /> opo <br /> sed(sl) System/Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> z <br /> New Tanks Existing Tanks U <br /> olding Iwo <br /> r12d 1-i Li Li Li <br /> Dosing Chamber i = <br /> VII.Responsibility Statement- I,the undersigned,a nine responsibi'ty for installation of the POWTS shown on the attached plans. <br /> PI er's Name( ' t) Plumbe 's Signature /MFRS Number Business Phone Number <br /> fS o"ev r' -- Uzi 22 �b p <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '7?'/S LuL-,,ti 2d --b W <br /> VIII.Coun /De artment Use On <br /> Approved _ Disapproved Permit Fee Date Issued Issuing Ag aturE <br /> _Owner Given Reason for Denial $ .jie> <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Rifnewbf 0 S , i & tt 2 <br /> Aaach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in sin <br /> SBD-6398(R.01/07)Valid thru 01/10 <br />