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z•i,,iyx1r:v4-.., County
<br /> 'VI Safety and Buildings Division t)6.1,..e., f C)
<br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.)
<br /> L\SP j,,1
<br /> Madison,fA11-43707-7162, , „,_....._
<br /> \‘'f'>i`\---7.-',re ' , tf, ftz., r: •;:-. p---.-7::::._
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<br /> Sanitary Permit Application nr.r. , ;State ransaction Number
<br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this fops tattle appAiriate lgo‘nge3141 unit' I
<br /> is required prior to obtaining a sanitary permit. Note:Application f , _'owned POWTS are subniitted to Laojeet Address(if different than mailing address)
<br /> the Department of Safety and Professional Servies. Personal informationiyou:po ' .,ig&hc.iised for seoanclassi,
<br /> purposes in accordance with the Privacy Law,s.15.04(IXm),Stats. ; 1 r1,-;•Pro:cr..-,,:-.-.!--. .:;;;;;7:4;,.--,..—i, ;
<br /> L Application Information-Please Print AU Information H--------:=7"-------------::- .4.
<br /> Property Owner's Name ^
<br /> 1 '7 1--1-----Partsel#
<br /> i
<br /> (_4''k k -es ,/,,i. , vioz k L
<br /> , 1 ■ ,
<br /> Property Owner's Mailing Address , i :i ; ,Lj . Property Location
<br /> (0(;) (f iti■,i-re,,,-1 Rd,
<br /> , —_ --.-.,;;LL.- _,i t
<br /> G-c,
<br /> vt Lot
<br /> City State a - Zip Code anebb _ . 7
<br /> 4 EA Section
<br /> kKietA,14,4e,e. W 1, '3'S i 7 ____
<br /> T 1 N; R % E
<br /> IL Type of Building(check all that apply) Lot# [
<br /> gl.or 2 Family Dwelling-Number of Bedrooms LA Subdivision Name
<br /> .-----
<br /> Block#
<br /> 0Public/Commercial-Describe Use
<br /> El City of ("-----
<br /> 0
<br /> CSM Number El Village of
<br /> State Owned-Desethe Use
<br /> 75- o g Town of S f>r%;%.5 C.(Q4A4 d
<br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' rig.
<br /> New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 00ther Modification to Existing System(explain)
<br /> B. l:3 Permit Renewal 0 Permit Revision El Change of Plumber I:Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> giNon-Pressurized In-Ground 0Prestarized In-Ground IDAt-Glade 0Mound>24 in.of suitable soil 0Mound<24 in.of suitable soil
<br /> ['Holding Tank E30ther Dispersal Component(explain) OPretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation
<br /> (.■0° 4 7 Is s IS 0 0 c().5'. c S S'
<br /> -
<br /> VI.Tank Info Capacity in Total #of Manuthoturcr ,0 A
<br /> Gallons Gallons Units .e) "g 6 T 0
<br /> New Tanks Existing Tanks
<br /> a 7:.C.) .6 3 ri. in ii:LI a.
<br /> Septic r Holcting Tank i L.S D _— i 6.5z): ( /A-Q.4.4 e_
<br /> Dosing Chamber
<br /> Vll.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name Trint) MP/MPRS Number Business Phone Number
<br /> Garti A -M e■sAiL0i.Z... Pt bejk...L's Signature YXj./.
<br /> Plumber's dress(Street,City,State,Zip Code)
<br /> t .. CA-- ■A..0 N) < LA.3 ciA3A e,„ ke.e LA...? 1, S..2 s ?
<br /> VIII.Coonty/Department Use Only I
<br /> Permit Fee 047 Date Issued g Signature
<br /> --ZApproved 0 Disapproved
<br /> 0 Owner Gwen Reason for Denial /4
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tit x II inches in size
<br /> SBD-6398(It 11/11)
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