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�Ew«rarkrrrJ County <br /> //0<4:, • �1 Industry Services Division <br /> �Q �h <br /> Ik ��; �� 1400E Washington Ave <br /> . : $,�. h ege P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> --- �C Madison,WI 53707-7162 \(-5..203— 2\Z. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application f s for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal iE <br /> rit <br /> y �,�r secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. Ze69 B 0..I 1 Qd, i., <br /> I. Application Information-Please Print All Information }� 9/ <br /> Property Owner's Name JUN 24 205 Parcel# b 7� I'` �1{e/ ) <br /> MtaP e rc.v� Firm l_L C Public Health►,tD6 Y Nikk <br /> environmental Health <br /> Property Owner's Mailing Address Property Location <br /> 1419 Coves`-y H W t `r Govt.Lot <br /> City,State Zip Code Phone Number p..)W %, Sid 1/4, Section 17 <br /> (circle one) <br /> d1l0.cshul1, w( _� loos 3S8 7 (Q y T g N R ( Eo i-N4- <br /> UI.Type of Building(check all . apt Lot# _ <br /> I or 2 Family Dwelling-Number of: 'rooms 5 Z Subdivision Name a V <br /> ❑Public/Commercial-Describe Use Block# 9 c <br /> d City of <br /> ❑State Owned-Describe Use <br /> -- CSM Number ❑ Village of <br /> 2G1 a, P 17 F Town of St,r. '�r�k r'e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rpi New System ❑ Replacement System ❑Treatment/Holding Tank Replacement 0 • Other M. .. - ' : ystem(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 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) ❑Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7�t7 Rate(gpdsf) O. 7 /87S 880 Sae_ Pl01' P1 \ <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer 0 2 U is <br /> New Tanks Existing Tanks Gallons Units o a. <br /> Septic or Holding Tank t 0 Do/6;50 I 0-CO I Mead e_ - ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu rber's Name(Print) P1 tuber's Signature MP/MPRS Number Business Phone Number <br /> - <br /> S\ n �e 5 171 e c ,.2,-111 (0 cgzo) 478-231 9 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N8ySg C.-00 r11-.) i4 0, Wo-te.rloo, ( 4 S3594-1 <br /> VIII.County/Department Use Only - i <br /> r <br /> Approved ❑ Disapproved Pen r it Fee Date Is ed lssuin. •ge.. kInfrao ra, <br /> • — �� <br /> Owner Given Reason for Denial —/,_ 'A� A <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Irz x 11 inches in size <br /> SBD-6398(R03/14) <br />