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County /�� <br /> ,"$"'' ,1. ft Li 4. Safety and Buildings Division PQ 11.e 1'1� <br /> D i-1 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �,., $ t Madison,WI 53707-7162 <br /> �; -iici 13-2 c' e \ � <br /> iC;,`_-m-�� <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information Y 4 7 5` Qi <br /> Property Owner's Name 6/c°C+irJO/ <br /> Parcel if <br /> vLQVf°L UCthdeh bur Z/ <br /> Property Owner's Mailing Address - 3 Q 3 7t7 -0 <br /> 3/ s n Property Location <br /> Thorson Orrt,e <br /> City,State Go t.Lot <br /> Zip Code Phone Number <br /> 0►u c le a, +sy ll SLC., r., kit) 1/1, Section 3!. <br /> II.Type of Building(check all that apply) S 3 s/r (circle <br /> ) <br /> T fr N; R 7 E oreW <br /> t or 2 Family Dwelling—Number of Bedrooms Subdivision Name ' <br /> (, Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of n <br /> Z/i t/ e� )4 1 Town of ae try <br /> III.Type of Permit: (C only one box on line` . Complete line B if applicable) <br /> ❑New System ®Replacement Syste ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 0t.1,L c &teaL <br /> B. ❑ Permit Renewal \ ❑Permit-Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration g ❑Permit Transfer to New <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all 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) <br /> ❑Pretreatment Device(explain) <br /> V.DisppersaUTreatment Area Information: <br /> Des Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sfl Dispersal Area P <br /> / ^ , ? I Pe Proposed(sfl System Elevation. / <br /> �� 7 S v /Z-- I /7 1r7e) ( ; Q t 7�3e <br /> �(L Tank Info' Capacity in Total #of an1G1 ufacturer � <br /> �__ Gallons Gallons Units 2 e <br /> New Tanks Existing Tanks u r?u u <br /> Septic or Holding Tank °B v in °' r' u;U is. <br /> /GOO t le(`` AOC' I 14/e sPr' jr <br /> Dosing Chamber 80 U <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'....': lure MP/MPRS Number <br /> KENNETH MEIER i' 224144 <br /> 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> ❑Approved I ❑Disapproved Permit Fee Date Issued Issuing A ign e <br /> ❑Owner Given Reason for Denial Si 21( , I '?q'i I <br /> IX.Conditions of Approval/Reasons for Disa rovaL� �`�' <br /> PA.U...b ^ 17JT ��k1� xZ33(T�3�4••►kg ARE_ S ci24.�L S U•a�l�A aTi 647 At.t <br /> �Z �C� � r�� �-e� /i4FF ° LVa.)6ieX-L q S T e..L- <br /> l`..1arE--: i'Aio 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 it I I inches in size <br /> SBD-6398(R. I I/I I) <br />