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socyA merr RECEIVED E C E I V E D Industry Services Division County <br /> i Vrk' e SEP 2'Y 1015 1400 E Washington Ave ail ivl: PD <br /> s -?1` P.O.Box 7162 Sani ermrt Number(to be filled in y Co.) <br /> ' <br /> Madison,WI 53707-7162 NEt-1( <br /> Public lent I HC 1, -.21N5*- <br /> :/ EnvirOn►rlpntal Heald' <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 forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. <br /> I. Application Information-Please Print All Information 15 15 Gri f rC „ <br /> Property Owner's Name Parcel# <br /> _, GiIlls Cl'lnwlllt iiflr i 0&�/e916-.1z--995(5 -6 <br /> Property Owner's Mailing Address Proper Location <br /> Ve) ,ICS 1l/e�P p 5/ii)d C 1 Govt.Lot <br /> Citye Zip Code Phone Number , 1 , <br /> S / J 7 SE ', N 1, /i, Section 1 Z <br /> �)Lt/J (/ei Ioe , illI ' l!a C_Q - 7 S3 ` (circle one) <br /> IL Type of Building(check all t. apply Lot# <br /> T q N; R fO EorW <br /> [II-112 Family Dwelling-Number of Be'..oms LI 1 Subdivision Name <br /> I Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CS�M Numbe ❑Village of _ <br /> (JfCii6gr/ ❑'lownof WItJOS/(!L <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement System ys p ys ❑Treatment/Holding Tank Replacement Only Illigir Modification to Exis�'gg System(explain) <br /> l_CJAJA/r_CTI0/4 <br /> B. 0 Permit Renewal 0 Permit Revision List Previous Permit Number and Date Issued <br /> ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner Cl S. 0 3 NS <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gon-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s f) Dispersal Area Proposed(st) System Elevation <br /> d 4/14- E%/1- A7/1- 11//t <br /> VI.Tank Info • Capacity in T 1 #of Manufacturer <br /> Gallons Gallons Units .2 o ¢o <br /> New Tanks Existing Tanks b V g id <br /> Septic or Holding Tank <br /> Dosing Chamber ie;:1-O U / `1 1 /"L 4 0 'C' , <br /> VII.Responsibility Statement-I,the undersigned,ass a responsibility for lnstallatio of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' • lure MP/MPRS Number Business Phone Number <br /> 5tEdi= DDEtIMS -,� � r,,,7ai3 l DJ' -stl tl-vy / <br /> Plumber's Address(Street,City,State,Zip Code) /� / <br /> S (ctrl DeAze /fl( idcKr(-� Frf'el,)al/`j1 a, J S I <br /> VIII.County/Department Use Only <br /> ❑Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> a -- <br /> ❑Owner Given Reason for Denial i + <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 Us x 11 inches In size <br /> SBD-6398(R.08/14) <br />