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y,..:nr.i i,.. County <br /> Industry Services Division E'ivt.e..__ <br /> D 1400 E Washinaton Ave <br /> S l-i Sanitary Permit Number(to be filled in by Co.) <br /> P S P.O. Box 7162 f <br /> •`'t Madison,WI 53707-7162 <br /> . SanitaryEt Application I State TransactionNutnber <br /> 1 <br /> in accordance with SPS 383 21(2),Wis.Adm.Code.submission of t litis form to the appropriate sovemmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fo-ms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s_ 15.04(1)(m).Stars. <br /> I. Application Information-Please Print All Informazior C/ <br /> Property Owner's Name Parcel R 'id ` 0 <br /> r <br /> r its.' ,,, �' t i MAY 13 2016 ( 1�` <br /> ! �'�t f C irk. _ .:fir . _ C 'f- C 1 .L i <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> Environmental Health <br /> j-- L A lb i C r'R -1,: . Govt.Lot <br /> I �r fit-- r, <br /> City.State Zi Phone Number -S 'A �{ '/-, Section y2 <br /> 1,�'- A f_ J 7I -:%q0 — (ct le one) <br /> r ✓ ! S i t/d�. tiLl r _ ,`z Lr be' 'r f7_.�% i?�f T ;7 N Ri E r W <br /> II.Type of Building(check all that apply) .. Lot= � <br /> 1 or 2 Family Dwelling-Number of Bedrooms _ Subdivision Name <br /> ❑Public/Commercial-Describe Use Block_ <br /> ❑ City of <br /> ❑ Villase of <br /> ❑State Owned-Describe Use <br /> r <br /> CSM Number I Z{Z•j(} <br /> �m4 I 2 Town of At+ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 24New System <br /> ❑ Replacement System ❑TreatrnentrHoldins Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 B. ❑ Permit Renewal ❑ Permit Revision I ❑Change of I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 1 Plumber I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ton-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 I Dispersal Area Required(sf) I Dispersal Area Proposed(sf) System Elevation <br /> 1-1" 5 Ratc(gpdsfl ` C.‘, <br /> Olt-) 9 E4' <br /> VI.Tank Info Capacity in V _ <br /> Gallons i Total I =of ... B <br /> Manufacturer i ; .= <br /> I Gallons I Units .L a 2 e; u = _ <br /> New Tanks Existing Tant:i I i I I —v' v; ' n — .z re- <br /> Septic or-R-sit'irg Tank x I J,Sc';JI - tril fYN,.?r.,"gIll .a t T I-E] Jrr ❑ I ❑ I ❑ I ❑ <br /> Dosing Chamber I I I f ❑ I ❑ I ❑ ❑ ❑ <br /> VII.Responsibility Statement- I.the undersigned,assume r.ponsibility fo install Lion of the POWTS shown on the attached plans. <br /> Plumber` N P,-;,Y) <br /> Plumbei s `kr j, BusinEXCAVATING & / ,�. , , ,, ? O c 1 ' - ?,--779:-c- i <br /> a.\ Plumbers cress tSt t e.Tin Cd e) <br /> 5245 N. oun` yoad ,( <br /> Janesville,WI 53545 E L /Ye-h1I /1 iA ? > KQAOi'J -Ei>w <br /> VIII.County/Department Use Only <br /> Kpproved ❑ Disapproved ' Permit Fee Date issued Issuing_ nt gna ec <br /> ❑ Owner Given Reason for Denial l S 1-P I ✓ 17 v <br /> jl IX.Conditions of Approval/Reasons for Disapproval . <br /> 1 <br /> I <br /> 1 <br /> Much to complete plans for the system and submit to the Couny only on paper not less than 8 to a 11 inches in size <br /> SBD-6395(R03(14) <br />