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1 <br /> • �/....17%,0. ~` �.r County <br /> ,tr\,, ;.,;;`,,�� Industry Services Division 2) <br /> 's 4`$ :I' r► q 1400 E Washington Ave <br /> `'� S;i AUG 1 .42115 P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> v;�a= , Madison,WI 53707-7162 ? <br /> Iiitlbilts Health M rC .7—20 t c- 00v26 i <br /> 3 if41% 1 8I1j1 - t • pplication 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 forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> • s in accordance with the Priva Law,s.15.0, 1 m,Stets. <br /> L A' 'lication Information-Please Print All Information <br /> Prope Owner's Name ( � a <br /> / Parcer# <br /> Property Owner's Mailing Address 0 09Q 7 Z Z — 2.0-6 <br /> - ko / Property ovation <br /> City,State <br /> Zip Code Govt.Lot <br /> / P Phone Number <br /> (1/,�/ 7 C. �, C' APE '�, �t E `�, Section �9 <br /> Lei D I S.3S J d62(-?e 3 .d3 Y/ T_l N; R circle ne) <br /> IL Type of Building(check all that apply) Lot# r W <br /> ❑'Cbr 2 Family / <br /> 2 elling-Number of Bedrooms T ) <br /> Subdivision Name <br /> ❑Public/Commercial-Describe Use �--, Block# <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> /39 r1, Y Pleirwn of n et2y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ©-Se;System Y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B, ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground EirrErrade ❑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.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design S/oiJ Application Rate(gpdsf) Dispersal rea Required(sf) Disper az1 Area Proposed v Le �/ P (sf) System Elevation <br /> VI.Tank Info /� / n Q `Jb' <br /> Capacity in Total #of <br /> Gallons Manufacturer <br /> allons <br /> Gallons Units <br /> New Tanks Existing Tanks <br /> w U $ ° <br /> c <br /> aU <br /> in 15 u t:C g's.or Holding Tack /ZOO — 1 Za6 " oSEfL �W g(��k L/Dosing Chamber rnQ <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 /> MP/MPRS Number Business Phone Number <br /> C' --(Street,l est&ty, r11t�QS y7 SOS-PI is Address City,State,Zip Code) V 7 r7 L/3 Z y(g d 7 <br /> E14Z57 aiefer _eL led I AMI1,Jda, &f 5 39[3 <br /> VIII County/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee `Date Issued Issuin — <br /> g Signature <br /> ❑Owner Given Reason for Denial f ��j 8 Z/ '5 j i`-' <br /> IX.Conditions of Approval/Reasons for Disapproval `fie; �� <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 vz x 11 inches in she <br /> SBD-6398(R0313) <br />