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�‹'~n Cormry 1 <br /> it�.ry \/t. Safety end Buildings Division d �( <br /> ti ,; 201 W.Washington Ave.,P.O,t3ox 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ; `7, '` Coil Madison,WI 63707-7162 <br /> , d Q036 Z <br /> Sanitary Permit Application StatoTransaciwnNumber <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Service. Personal intbmation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(lXm),Stets. ( <br /> I. A licationInformation-PleasePrintAllInforntation �� V�r <br /> �Pro Owner's Namo P s o1# <br /> a/ifao 0.1444 S/iJk7 Q , �i �t c. Q�� 7 �'! "6> 3)- <br /> perry Owner's Mailing Addr // y� /� Property Local.n <br /> C�r !.� ��rte/ r. 1. Govt,Lot <br /> Ci�tyJ State /�� �q Zip Coda ` Phone Number <br /> (� 'A, Yr,Section <br /> }rwl:/1QICI, y v" f'+ `I i�vCl 7 /O 1 T Ni R (ekclgor V <br /> II,Type of Building(check all(lint apply) Lot 0 <br /> — <br /> iklor2FamilyDwelling-Number of Bedrooms �/ SnClxl�ivls Ion Name�/� 41:e Blochti ! X. lac rd I�(U.+r LCi,c <br /> l JPublic/Corn meroial-DescribeUse Li City of <br /> CSMNumber 0 Village of • <br /> 0 State Owned-Describe Uso <br /> �'own of <br /> ;:?t:,Y '-r <br /> IlL Typo of Permit; (Check only one box on line A, Complete lire B if applicable)• <br /> A. LINcwSystenr 0 Replacement System Treatment/Holding (�Otherb edification to Existing Syste (explain) <br /> 0 Trcalmcnl/tloldin , <br /> I <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber <br /> ❑Forth ll1ransfertoNew List Prnvi.os Prssit Nun,•.r and Dut Issued <br /> 13efore Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurised In-Ground 0 Pressurized in-Ground 0 At-Grade 0 Mound>24 in,of suitable.soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/freattuent Area Information: <br /> Design Plow(Bpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st)_____ Dispersal Area Proposed(s0 System Elevation <br /> VI.Tank Info Capacity in 'Total ft of Manufacturer <br /> ii <br /> Gallons Gallons Units I.a B H <br /> New Tanks B.dslingTanks t I w A M <br /> Septic or Holding Tank <br /> Dosing Chantzr <br /> VII,Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shonn on the attached plans. <br /> Phut bee's Name(Print) Plumber's 3igna re MPPs11RS Number Business Phone Number <br /> PI tuber's Address(Street,City,State,' .C ) _ <br /> �D•` r` GLV. 1 C _C4 .Las .53. 70 -- <br /> VIII.County/Department se Only <br /> 0 Approved 0 Disapproved <br /> Permit Fee Date Issued Issuing Agent Signature <br /> O,„cr Oiven Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1 Armco to complete plans for thesystem and tabmlt to tho County only on paper not less than a tux 11 inches In stze <br /> SBD-6398(R.11/l l) <br /> • <br />