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I <br /> r County <br /> Safety and Buildings Division <br /> �l 201 W.Washington Ave., P.O. Box 7162 19 4 4-e r <br /> Sanitary Permit Number(to be tilled in by Co.) <br /> ,, `),==S!.123, <br /> ,. Madison,WI 53707-7162 <br /> r: ( 3 -2 of s—6o�a ` <br /> `Rf-�NIn.�.��' 4/J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal informatio .0 • •v'•- lt . sed for secondary <br /> .0 .oses in accordance with the Privac Law,s.15 i t , Ilta <br /> I. Application Information-Please 'rintAll Infi rmation ' r = / i y� <br /> Property Owner's Name 1 I//r �G( <br /> /�''' ' ��9rn-tS R _6 2015 Parcel#�e ��'�5 �i <br /> • <br /> rnUrt of �G4✓ Lee S .e-,!?1• LL �- <br /> Property Owner's Mailing Address Pub �� ��� _����� —© <br /> ealth MDC Property Location <br /> Z 3 v 3 tn, n) df(� ronmental Health <br /> City,State Code Govt.Lot <br /> Phone Number <br /> Lo-CL tt (� ca 1/+, SW '4, Section 1 <br /> 5.f.5 (circle one) <br /> II.Type of Building(check all that apply) Lot# T N: R E or W <br /> j24-I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 1 (J Town of Oa it e_ <br /> EU.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ill Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground El to 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(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of'M ' "`"C �� I ���' <br /> Manufacturer <br /> Gallons Units 8 C <br /> Gallons <br /> New Tanks Existing Tanks <br /> '� V v ; <br /> .0 Lag a g is <br /> Septic or Holding Tank /? G <br /> e.U iiz ,,, o w V C. <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature <br /> KENNETH METER MPMIPRS Number <br /> 1(. .: 37 224144 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> pproved ❑ Disapproved Permit Fee di/:,)Date Issued Iss 'ng A,,�ignature - <br /> ❑Owner Given Reason for Denial / 6 -/O -/S"- <br /> IX.Conditions of Approval/Reasons for Disapprov I <br /> ~� / <br /> .X.e0e:&L---6,„-- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/z x t l inches in size <br /> SBD-6398 IR. I I/I I <br />