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County <br /> '4'�•f <br /> /�' "�'„.- Industry Services Division /3u,v,vt-C� <br /> G� r; 1400 E Washington Ave Sanitary Permit Number.(o be tilled in.by Co.) <br /> ._ ) Q7 <br /> P.O. Box 7162 5p <br /> {, ��;y Madison, WI 53707-7162 �j�_`) _9 <br /> StateTransaction Number <br /> Sanitary Permit Application <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 mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. A licationInformation—PleasePrintAllInformation <br /> Property Owner's Name Parcel# p f <br /> /'Yl ar l�v-ow In o�� od8-d-10-15'-!9 <br /> Property Owners Mailing Address Property Location _TCLy �,D <br /> 3 0 A Govt.Lot (,d 7 <br /> City,State Zip Code Phone Number %, %, Section <br /> �I/L h 314'✓ WL 5�l�r!3 (circle one <br /> 11.Type of Building(check all that apply) Lot# T y d N; R_L�E o� <br /> 4 1 or2 Family Dwelling-Number of Bedrooms 1) 2 Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial-Describe Use <br /> ❑ City of - <br /> ❑State Owned-Describe Use `CS IM Number <br /> 2 ❑ Village of <br /> V t I l J5 Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Replacement System p y Y (explain)❑Treatment/Holding Tank Re lacernent Onl ❑Other Modification to Existing System ex lain) <br /> B• Permit Renewal El Permit Revision ❑Change of PlumberTown- <br /> IV.1yp,eermit Transfer to New List Previous Permit Numberand Date Issued <br /> Before Expiration <br /> .of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> ❑`Nan=(?ressirrized 1•n-Ground ❑Pressurized[a-Ground ❑ At-Grade N[ound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> Efa.[anTaiik El other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD s'"ersaI/Treatment Area Information: <br /> De95-FR-w(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> '3Qb 8g fop �.�6 4 6, 7 <br /> VT.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .n U v <br /> New Tanks 0. <br /> Existing Tanks 2 0 2 a <br /> c.0 in y <br /> { <br /> Septic or Holding Tank 7 SO •7S0 W C/- <br /> ✓C <br /> Dosing Chamber- ?S,b �7 S�0 J 4/-e J S P <br /> V11.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IvIP/MPRS Number Business Phone Number <br /> �Zi LIG � 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,C 7 7G o ,�,., 3s w-r,�s�c w f`-r S 93 <br /> VIII.Coun /I)e artment Use Only <br /> Approved ❑Disapproved Pen it Fee Date Issued Issuing Agent Sim lure _ <br /> ❑ Owner Given Reason for Denial <br /> �25 <br /> IX.Cporiditions of Approval/Reasons for'Disapproval <br /> r[ i13 2004 <br /> kDllcw ajL cmni{ aid S-I-ak f-e?c4J&_r►LP_n-kS <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 112 x 11 in!has in did S@fVIC@S Department <br /> ��125 cl�t.eck t�5�y�g <br />