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,r�yiuri`,y County <br /> / < �,,, Safety and Buildings Division µe N If- <br /> Jr <br /> (. <br /> C I t <br /> 13't r 0 r* 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t gps` J� Madison,WI 53707-7162 <br /> 55123 <br /> Sanitary Permit Application State�T 5%acctionN�u/�mber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit `�0 V I`1 view <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 may be used for secondary /� p <br /> 2urposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. '7aL�y F/eN1.Sfrdr (/c <br /> I. Application Information—Please Print All Information _ <br /> Property Owner's Name Parcel 4 &7.0 V <br /> GetnG pa t /5-5'7a--4Dy_4,oa0 <br /> Property Owner's Mailing Address Property Location <br /> 74 5'7r gra.,-4 17oP <br /> Govt.Lot <br /> City,State Zip Code Phone Number y,, V, Section <br /> DOnbu im , tNjT_Y 830 (circle one) <br /> 11.Type of Build- (check all that apply) ✓ _� Lot N T 40 N, R�_E ore <br /> 10 1 or 2 Family Dwelling—Number of Bedrooms S Subdivision Name <br /> Blo^ckk AI(LAWA S11cLfi6 <br /> ❑Public/Commercial—Describe Use A <br /> ❑ City of <br /> 0 State Owned—Describe Use CSM Number 1),&C 0 Village of <br /> 360906 Of Town of 041k <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System 0 Replacement System,q y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a I ) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 inofsuitable soil 0 Mound<24 inofsuitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> 4.s0 •7 G43 C-,4lf W. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units in <br /> New Tanks Existing Tanks m e v = u s m <br /> a U v: c- <br /> Septic or Holding Tank lOS"O /O.1'O / rq sf�` f w.{p r <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,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 /> R/cle, /ya /[f n s �Z .O /j� � 8a 1 r/s-.9AA -7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 7 7G a /l 3S 64-1e6,,1-e, otrf <br /> VI11,Coun /De artment Use Only Approved 0 Disapproved Permit Fee Dale Issued '^ Issuing ge Sigmnure <br /> ❑Owner Given Reason for Denial <br /> $ ,3Z5-4F0- 3 (�A`( CU�2 <br /> ]r.Conditions of Approval/Reasons for Disapproval <br /> Attach incomplete plans for the system and submit to the Countyonly on paper not less than ll In x 11 inches in size <br /> SBD-6398(R. 11/11) <br />