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County <br /> ! _ Safety and Buildings Division D ct 14 E. <br /> /0 1 D :' : 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SP ' Ti Madison,WI 53707-7162 <br /> 1:�� S fii t <br /> Sanitary Permit Applic //'�y State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this fo r a f41/Init -2-5--C-2 e p <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} asy <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. r7/o�.- - t L jJ p V <br /> I. Application Information-Please Print All Information RECEIVED l IptJ 7 / (f <br /> Property Owner's Name Parcel# <br /> low, o-F tie,oNc 0408—og2-9220_0 <br /> APR292016 <br /> Property Owner's Mailing Address Property Location <br /> 3 3 •- _r_ //, tE / 2.VV2 Public Health MDC Govt.Lot <br /> City,State Zip Code rrivir'bH,1.e(h eHealth 8 <br /> e� ►7 �j .�k/ '/., poi '/,,Section <br /> U e r0 k (n)1 S3,S Q 3 r03r e3 YS - (� e/ ,,�,.f(circle one) <br /> II.Type of Building(check all that apply) Lot# T�? .N; R �j [�or N <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> -� Block# <br /> VIM��M 11141_i- <br /> 4G-c- tT HST E1 City of <br /> �p <br /> ❑State Owned-Describe Use CSM Number ❑ iage of <br /> W Town of rt‹ i9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> p-isiew System ❑Replacement System ❑Treatment/Holding Tank Replacement OY ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Pemtit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground El Pressurized In-Ground ❑At-Grade ..34ound>24 in.of suitable soil ❑Mound<24 in.of suitable soil r C,� <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain) <br /> £Cfl/ �}?rtcsAt. <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Are3Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 13841 0.6 2723 .trAr.9 . � (o5'9. s' <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units V o <br /> New Tanks Existing Tanks eo v u I i m <br /> 6t-'3.- I,con) _ i t e--c. a`,y 3 u co a <br /> Dosing Chamber <br /> l I0C C �i 11rr��b,,et <br /> VII.Responsibility Statement-Cement I,the undersigned,assume respyn t3B my for installation of the POWTS shown on the attacfied plans. <br /> Plum er's Name(Print) Plumber's Signature MPfe4P Number Business Phone Number <br /> /VLc I4.4wer t ZEDt;77 CG48�Z20-0`!8Q <br /> Plumber's Address( treet,City,State,Zip Code)) i� <br /> 312(. WeciT-orc� t.ilGy1 l ta�tSoto f i3O� S3'7/3 CPIr/ <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issui ,Agent rt 1 <br /> Approved ❑Disapproved <br /> $ � �� <br /> p <br /> ❑Owner Given Reason for Denial 1 1 15 ( 9 / -. <br /> IX.Conditions of Approval/Reasons for Disapproval �,G i <br /> OP(7. ��(KS e (o-� 3-/-7// ,, <br /> -J� T-K�l( -4,Q . Lj <br /> 26,27 (/,4 r tolfc 1164,004- -2 tic <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 x 11 inches in size <br /> fl t p i 4 V A O G i 4 M e a t- M -g fr o, PFP. Caf <br /> SBD-6398(R.11/11) f <br /> r <br />