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i uotnit)' ,y r Y� s ., 112411 1400 E Washington Ave �� — — >!. P� VI `, P.O. BOX 7162 Sanitary Permit Number(to be filled in,)) C;.. _ -- v 1l Madison, WI 53707-7162 Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to ___ the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I. Application Information-Please Print All Information Property Owner's Name — — F n Uf fA c J ;4� Parcel N a c bolt i 3 C�r kQ._ (2,Zy/0 7 i.2_, -1 9 3 Zc)c-, . c, Property Owner's Mailing Address Property I,ocai:ca . 7 iii Dtz;z_eTZQA0 'R0( , , Govt. Lot City,State Zip Code '• Phone Number 6 1.4.,1 1/4.,S to/,, Section / Derr :e_\ a , w I 53 5'3 I 1..0% 74,4 `• 't7 4, (circle one) 1' 7 N ; R / E(44-1,\J- II.�jType of Building(check all that apply) Lot q p � F 1 or 2 Family Dwelling-Number of Bedroortj 7 s C Subdivision Name ❑Public/Commercial-Describe Use I • Block 4 0 State Owned-Describe Use ❑ City of CSM Number ❑ Village of ,� f� /6. 73 C ' Towi)of Ue_zt'-F.Q.iGI HI. -------------- Type of Permit: (Check only one box on line A. Complete line B if applicable)— _ A. ❑ New System IS Replacement System ❑ Treatment/Holding Tank Replacement Only [] O hu 1oil f: il, to iai,iiii Sil,ii. ,;,.., B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Da;,lss..ed Before Expiration Plumber Owner IV.Type of POWTS System/Component/Device: (Check all that apply) — _ t Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation 6..0 O Rate(gpdsf) O / SOd / S o 52? P16\ t1ct VI.Tank Info — Capacity in T —— -- Gallons Total ii of y Gallons Units 'Mancinckr-el _ New Tanks Existing Tanks 2: li s J _. Septic or�k- 8�4 y� � — I ZSio, f M 2 a ck —.61 ❑ t �_E -r - --.i._f l . Dosing Chamber - ❑ ❑ 1 u U VII.Responsibility Statement- 1,the undersi ned,assume responsibility for installation of the POWTS shown on the attached plans. Plu fiber's Name(Print) P ur ber's Signat e MP/MPRS Number Business Phone Number Sevo_Y� 'Te5 m ---� t1/4, `/� 22-1 l■ (n 1c20) 47$ 237 Plumber's Address(Street,City,State,Zip Code) ms 4 s-8 C_b o o.i f49 U 1 W ai e_c f o o , (N i 53 S. 9 Li VIII.County/Department Use Only ❑ Approved ❑ Disapproved ( Permit Fee Date Issued 1 Issuing Agent Signature ❑ Owner Given Reason for Denial S IX.Conditions of Approval/Reasons for Disapproval I i Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x t 1 inches in size - - SBD-6398(R03/14)