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Cdr. it`q <br /> f1 County <br /> �1 Safety and Buildings Division 0 - <br /> t%�SP " 201 W.Washington Ave.,P.O.Box 7162 'V <br /> $ ".� Madison,WI 53707-7162 S8° ParmitN�her(to be filled in by Co.) <br /> 13 -2drs- 3 <br /> Sanitary Permit Application SffiCe Transaction Number <br /> In accordance with SPS 36321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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(1Xm),Stets. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel 4 <br /> do,t,,. Po OSiot-0-7y-Qoo°-I <br /> Property Owner's Mailing Address <br /> '36 Property Location <br /> �A.7■X16 W 1 r.. <br /> City.State Zip Code Govt Lot <br /> P Phone Number <br /> N is %., s(_ Y..,Section <br /> F J.qsc e 4-o h1 WT 53539 6og•A45-1g3C-r (circle one) <br /> IL Type'6f Building(check all that apply) Lot# T N; R _ W <br /> Ni I or 2 Family Dwelling-Number of Bedrooms 9 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block 4 <br /> ❑City of <br /> ❑State Owned-Describe Use - CSM Number ❑Village of <br /> 0Townof AtbiGNi <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System Re Y <br /> Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to <br /> Busting System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber <br /> List Previous Permit Number and Date Issued <br /> Before Eapitatioa 0 Transfer to New <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> it Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in of suitable soil ❑Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Device(elf lain) <br /> V.Dispersal/FreatmentArea Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdst) I Dispersal Area Required(sf) I Dispersal Area Proposed(sf) I System Elevation <br /> GOO •- 951, t 41 qoo <br /> VI.Tank Info 95: <br /> Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks 'BE' 8 T .° <br /> Septic oeiialiiog Tank ae.U r-yn. yr 5 y I <br /> 1000/.300 — 1300 / bG/ . - ./ <br /> Dosing Chamber -7 5 0 — 750 / <br /> V <br /> X. <br /> II Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature <br /> MP/ivffRS Number Brisinns Phone Number <br /> 'sT,,:.-to-1Av.i J3z11e. /. 1 a9.-7595 6o G.-V.6-74/66 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1330 Fri-{-x QA. l/et-ory G, WS 53 59'3 <br /> VIII.County/Department Use Only <br /> Approved I❑Disapproved Fee Date Issued Issui ant J�,",,',','�, <br /> ❑Owner Given Reason for Denial LPermit <br /> $1131 �'� 1 �� ;����_/J <br /> IX.Conditions of Approval/Reasoas for Disapproval 1/ ry 1 D F <br /> Pga, t y 4.64, okP .s ue ryf -i-, <br /> / /���� <br /> SBf D- <br /> Attach to complete plans m for the system and submit to the County only on paper not less than a In x 11 inches size <br /> /D-663j98(R.11/11) <br />