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;c" <br /> .W1.gOV Safety and Buildings Division CountyR <br /> 201 W.Washington Ave. PO Box 7162 J�L) N ETT <br /> onSin Madison,WI 53707 7162 Sanitary Permit Number(to be filled m by Co.) <br /> of Commerre x i. r <br /> � v � Ir+'ol.�t is€-- c <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wu.Adm.Code,submission of this form to the appropriate govemmental 4:.OQwt-Y tut e V t ew <br /> unit is required prim to obtaining a sanitary permit Note: Application forms for state-owned POWTS we Reject 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,a.15.04(l m Stab. ,✓/ <br /> L A cation Information-Please Print All LJoamatim ( 7 T V VA Qt K ROAD <br /> Property Owner's Name Parcel# (0/2 gzIs 03310 Lgacy ZO <br /> �osapr( l sRct{ l -z 1(0 15 25 5 <br /> 05•0d- <br /> Property Owner's Mailing Address Property Location <br /> 4&7 MYRTLE COUPT Govt Lot I <br /> City,Stat Zip Cede Phone Number Yy Y, Section <br /> 25 <br /> MRDLT:WpO MN 55119 (cycle one) <br /> T 40N; R_16 sorW <br /> V1 in <br /> of Building(cheek all that apply) Lot# <br /> 17f I m 2 Family Dwelling-Number of Bedrooms .2. 1 Subdivision Name <br /> Block# f <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑Stat Owned-Describe Use CSMNumber _1"33-7 <br /> Village of <br /> Irl Town of /TdK'KSOrt <br /> Vol. IS fLK 25Z <br /> III.Type of Permit: (Check only me box an ante A. Complete tine B if applicable) <br /> A. New System Elgeplaccancrat system ❑Treatmod/Holdm8 Tank <br /> Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ PermilRaewal ❑Permit Revision ❑Charmge ofPlmnber ❑Permit TranfertNew <br /> List Previous Permit Number and Dat Issued <br /> Before Expiration Owner <br /> IV.Type of POWIN tem/C® t0evire: Check all that apply) <br /> 0Non-Pressurized In-Ground 11 Prro <br /> eaunized In-Gund 11At-Dade ElMound->24 in of suitable wil ❑Mwnd<yt in,of suitable soil <br /> 17J Holding Tank ❑Other Dispersal Component(explain) ❑Prearatment Device(ccplam) <br /> V.Dispersialfrreatmend Arca hdormatim: <br /> Design Flow(pd) Design Soil Application Rate(gpdaf) Dispersal Area Required(sf) Dispersal Ara Proposed(sf) System Elevation <br /> 30D <br /> VL Tank Ltfo Capacity in Total #of Manufacturer <br /> Gallon Gallon Unita v $ <br /> New Tanks Exiadng Tanks `g Q Vaj `� y dd <br /> Septic or Holding Tank /355.4- /(o(o(a J8999 .Z SKAv✓ ✓ <br /> Doing Chamber <br /> VB.ResponsibBi Statement-1,the undersigned,assume responsibility fm installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SSi nahue WAVES Number Business Phone Number <br /> Rick HoP t'n Z� '2d-5-005 71:5 &e;o 'f-!s"T <br /> Plumber's Address(Shoes,City,state,Zip Code) <br /> 7(00 14Wi 3Wab5te r WI 5-W" <br /> VIII.Coany./Department Use Ont <br /> O <br /> Approved El D®approved Permit Fee Dat teased Issuing All alive <br /> $ YY <br /> ❑OwnerGivenRaisonfm Denial 375�A 4 Jac 201( <br /> M Cmditims of Approval/Reasons for Disapproval <br /> 5/64 O4f5 rat AS,- 5oFA4,4,E GtAdi* � fed scEbef� �rq.,,q(s roes OHwYfah �fu .�alfar?,t <br /> /%ffA sr>»d kaAk Far a iso es«frn.l Maoid Errs sod/ Avwr,.d" cell. <br /> Abash to ear phte plan for the syswo and subMk ttht Coumy arty an paper rat las than 814 s 11 tent In the <br /> SBD-6398(R.02/09)Valid thin 02/11 <br />