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pPAR . R E V/E I Y E D County �4,-----,-,a r Industry Services Division i_Jt.� n� /4t` D xK, 1400 E Washington Ave i $p S ),I APR. 0 1-2016 Sanitary Permit Number(to be filled in by Co.) P.O. Box 7162 rah �� Madison,WI 53707-7162 4„A,`___:nra/ Public Health MDC 1 .- 2DI f� 6 '7 -!t sum"=' Environmerltel HP11th r� vw j Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 1. Application Information-Please Print All Information CO V1/4-.n 4--y Nig h w(x'J i N/ Property Owner's Name Parcel 4 AI I,✓n tT C-li,°rko v I- a- Rach® I R kh ick►viej-er o5 la -o5a-8835-0 Property Owner's Mailing Address ` Property Location 1481 C,o wn -H i"t l 9 Vw\)a V V' Govt.Lot City,State Zip Code Phone Number N W ''A, Nv41/4, Section OS StpUgh-l-on wi 55 5E (a z- I TO5 N IZ ; R (circle one) II.Type oft uilding(check all that apply) Lot k �/ FA 1 or 2 Fancily Dwelling-Number of Bedrooms ' 3 I Subdivision Name ❑Public/Commercial-Describe Use ______ Block 4 ❑ City of ❑State Owned-Describe Use CSMNumber ❑ Village of 1 I a (�/ Town of A I b I L"n III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. "New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV.Type of POWTS System/Component/Device: (Check all that apply) .Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 45 ° Rate(gPdsf) O- r) 'i I 1. i (3 o< iUU. S l O I.S VI.Tank Info Capacity in Gallons u o 'er �?•Total of Manufacturer '° U " Gallons Units 2 2 g i� New Tanks Existing Tanks ,U un u.CD tz. Septic or Holding Tank ,So/3Sc0 /6.9c50 I m e Uc e:)'� a_ ❑ ❑ ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ ❑ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plu gnature 'I MP/MPRS Number Business Phone Number • ,�' . I Yl e I' / 'd _. q o )"7 • ._a1. Ll 1-52. 1 Plumber's Address(Street,City, Zip Co' / - NB4S2 Co. Rd O wot e t- l oo i w ( 5559 0 VIII.County/Department Use Only ❑ Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial $ IX.Conditions of Approval/Reasons for Disapproval . Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size SBD-6398(R03/14)