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fi `\ Safety and Buildings Division County pane 1 <br /> �1 201 W.Washington Ave.,P.O.Box 7182 <br /> i°` ''`' j) Madison,WI 53707-7182 Sanitary Permit N er(to be fi led in by Co,) <br /> ..owns)- Sanitary Permit Application stare Transaction Number <br /> In accordance with s. Comm. 83.21(2), VNs. Mm. Code, submission of this form to the appropriate <br /> governmental unit is required pdor to obtaining a sanitary permit. Note: Application forms for state- Project Address(if different than mailing <br /> owned POWTS are submitted to the Department of Commerce. Personal information you provide may address) <br /> .beAppIttatiaradneursdleassEleassoRtinbAlistanostlarty Law,a.15.04(1)(m),State. <br /> Property Owner's Name <br /> Parcel# <br /> RYAN&STEPHANIE BAL.LWEG 050/0907-184-4529-0 <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State I Zip Code Phone Number <br /> 'A, 14, Section <br /> (circle one) <br /> II.Type of Building(check al that apply). Lot# T N; R E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms 29 Subdivision Name <br /> Block# Biackhawk Fields <br /> Publlo/Commercial-Describe Use City of <br /> CSM Number Village of <br /> State Owned--Describe Use Town of Roxbury <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System <br /> m <br /> Syste <br /> (explain) <br /> Reconnect <br /> B. Permit Permit Revision Change of Permit Transfer to List Previous Penrdt u and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check al 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.Dispersal/Treatment Area Information: S Y 47fl. #j £.rvr 71i d /G--/ 2-61/2..-- <br /> Design Row(gpd) Design Soil Application' Dispersal Area Required(at) Dispersal Area Proposed System Elevation <br /> (�C)-� Ragpd�) r((�ebw ry r-rc---- <br /> VI.Tank Info Capacity in Total #of Manufacturer Si <br /> Gallons Gallon Units <br /> New Tanks Existing Tanks a <br /> av tov a <br /> Sep&orraiding Tank .--^ bat lg2a° Z p t V <br /> Dosing Chamber .rets, .5-0110 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWr8 shown on the attached plans. <br /> Plumber's Name(Print) ' Plumber's Signature MP/MPRS Number Business Phone Number <br /> Brian Eising <br /> 1005477 608-432-4687 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> El 0257 Greimel Road, Baraboo,WI 53913 <br /> VIII.County/Department Use Only <br /> Approved Disapproved Permit Fee Date Issued Issuing Agent Sig ure <br /> ,V/ Owner Given Reason for °�7 )0.--S-' ,� ( 4/10\r"Denial / <br /> rY CA-Lt.. P uC- //e'it& ej'MO/ ¢ JAS C9 M(ri <br /> A 7 bas-2,''z—6s7s— J32 :.lice -c A( ,�,,2(0,t. 7 • • < 4 <br /> SBD-6398(R.10/11) <br />