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C my <br /> ' Safety and Buildings Division <br /> e= <br /> ^. p S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> gS Madison,WI 53707-7162Qo�9 <br /> Sanitary Permit Application StatcTransactionNumber <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 fortes 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 <br /> purposes in accordance with the Privacy law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> C ,g e1 <br /> Property Owner's Mailing Address Property Location <br /> W 1/P8D vP/ Govt.Lot <br /> C) State State Zip Code Phone Number y, -ate y, Section <br /> yrt�t 1 1 tt� l�l�O'�,I !�A rcle one) <br /> Ill.Type of Building(check all that apply) Lot# E or W <br /> X1 or 2 Family Dwelling-Number of Bedrooms �" Subdivision Name <br /> Block# <br /> ❑PublicXommercial-Describe Use <br /> ❑City of <br /> ❑State Owned Describe Use CSM Number ❑village of + <br /> T Town of Jq1 G d// <br /> LII.Type of Permit: (Check only one box online A. Complete tine B if applicable) <br /> A. ❑New System ReplacemenSystem �Treatment/HoldingReplacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit.Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date ssued <br /> Before Expiration Owner 1��s✓1 `(-cCj­ a <br /> IV.Type of POwTS S'stem/Com onent/Device: (Check all that apply) AQ <br /> Nan-Pressurized In-Ground ❑Prcssurizcd hi-Ground ❑At-Grade Q Mound,24 is of suitablesoil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) - ❑Pretreatment Device <br /> V. Dispersal/Treatment Area Information: <br /> Design Plow(go) Design Soil A plication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3� . 9 y�'o 7i a f i <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 0� � U <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank OQJr— <br /> Dosing Chamber J' <br /> VII.Res onsibility Statement-I,the undersigned,assume responsibility for installation of the PON TS shown on the attached plans. <br /> Plum Name(Print11 Plum gnaturc MPtMPRS Number Business Phone Number <br /> =566-0zoZ. <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 72�d .)qt M(Sam�c� �Je�sr4r- bit' S109 <br /> rrrViiilll.County/Department Use Only <br /> til Approved ❑Disapproved Perm2it Fee Dilate Isstrcd Issuing Agent Signature <br /> " ❑Owner Given Reason for Denial $ �l 7S-. O� O - �D + =^ FLM n VkJ <br /> IX.Conditions of Approval/Ressons for Disapproval <br /> AUG 10 2015 <br /> Attach to complete plans for the system and submit to the County only on paper rot less thae®trz i <br /> ZONING <br /> SBD-6398(R. 11/11) <br />