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County <br /> / ! � Safety and Buildings Division StA e <br /> ,19,1B Ya ,` rl 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> j Madison,WI 53707-7162 <br /> 5.Z <br /> 30 <br /> Sanitary Permit Application State Transaction Number ( n <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2072513 V �_ <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1 xm),Stats. PrQ•S n--G f- <br /> 1. Application Information-Please Print All Information T <br /> Property Owner's Name Parcel q 07 Oat O-)f4 O /fv TOS <br /> 10eisr//S 8�/ter 930 / 31&00 <br /> Property Owner's Mailing Address Property Location <br /> /4/4S DIC6Y ?^i k Govt.Lot <br /> City,State Zip Code Phone Number ', '/,, Section 010 <br /> /Zot c anOu✓ t A?/// 15-S-60 S 6sl- See- 4ss9 <br /> T q0 N; one) <br /> N; <br /> II.Type of Building(check all that apply) Lot <br /> I or 2 Family Dwell ing-Number of Bedrooms d /$ Sudivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use / & ❑ city-q. <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of QR&1a r"�• <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) - i- <br /> A. OCNew System ❑ Replacement System ❑ TreatmenUHolding Tank Replacement 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 Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent(Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in,of suitable soil ,2 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> p0v /•d 300 3.?f 1 -14-. 5-3 <br /> VI.Tank Info Capacity in Total M of Manufacturer u <br /> Gallons Gallons Units V v 9 <br /> New Tanks Existing Tanks v o :: 0, n <br /> iL <br /> Septic or Holding Tank 79'0 7s-o <br /> Dosing Chamber 6,116 SOO <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 /> z< tc/C /i% t fZc.r�.-ep /7 I�S�T/ 9/S-8d6' N/S"7 <br /> Plumber's Address( neer,City,State,Zip Code) <br /> db77/oD 3S W�bsfr� f�L Sal rf9 <br /> V IL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing ent Signature <br /> El owner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <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. 1I/1I) <br />