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YNrr '. -\ County /�l x Safety and Buildings Division �'''A� /611 ,$7 0' . 201 W.Washington Ave., P.O. Box 7162 Sanitary Pe�nit Number(to be filled in by Co ° 1S.;01:' Madison,WI 53707-7162 ., � 0 13 -- �. a1to — O0 1 3 Sanitary Permit Application State Transaction Number I,Zr o-dance with S1'S 383 21(2),\4'rs 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 Project Address tit'different than mailing addressi the Departmcni of Safety and Professional Servics. Personal information you provide may be used for secondary rinses in accordance with the Privacy Law,s 15 04(1)(m),Stats. f I. Application Information—Please Print All Information _,_ ,_ rPmts Owner's Na ne - Parcel H //1')-(' / 4%� (_ 6) T y/-iti,1/ MAY 2 3 2016 C, 0�002-�l ley Vt` i-o Property Owner's hlaili ddress Property ovation . {j t .lic Health MDC �/� 0 U /`L,�" N f `` i ` t" ;' .... �s� l:Cl� - Gov',Lot Jv 1 cit State I Zip Code Phone Number SO ,' i 9 j/ .- Section --- 1 d /ZC (1 C J / L+lj�,. I �- / O6' 6 3 L9 4 —t(circle one) II. C)pe of Building(cheek all that apply) Lot a -1 or 2 I'amily Dwelling--Numbet of l3edrooms ( Subdivision Name Block a PubliciCommerctal-Describe lfsc lip of iD State Owed-Describe Use CSM Number ❑ Village oOwned 911 rown of P G_ bur I — — I . III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) LJ Nev:System ❑ Replacement System ❑Treatntentllloldmg Tank Replacement Only i Other Modification to Existing System lcsplaut 1 J Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issue, (1• ❑Change of Plumber ❑Permit Transfer to New 13ehdre I xpiratwn Owner I .Type of POWTS System/Component/Device: (Check all that apply) ❑ N'on-Pressunzed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ mound,24 in of suitable soil ❑ Mound e 24 in of suitable soil ( 4 ❑ Holding rank U Other Dispersal Component(explain)_ -_--_..... ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information — — I Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation \'I.Tank Info Capacity in Total H of Manufacturer Gallons Gallons Units _a v o i New Tanks Existing Tanks c v 1 c - ` c X — — S:ptic or IIotd,ng Tank - i------ i I I — — — -- — - .—-- —— --- )— r i unn tg t.hamh:r I VII. Responsibility Statement- 1,the undersigned,assume respo, ibility f r installation of the POWTS shown on the attached plans. - Plumber's Name l'riot) Plumbc 'ignatu MP/MPRS Number ' Business Phone Number 1_1 ri I ill-__ ari __I — /02.04-/SS" aDey30 / I Plumber's Address(Street,City,Sta ip Cove) 1 gC3 / e' s (dry i&J2 r, w s' 3 S---76) 1 VIII.County/Department Use Only _. -.a Approved ❑ Disapproved t Permit Fee Date Issued Issuing _• 'nature ❑Owner Given Reason for Denial S 4.0 J b3//,, .-•" ---: /F IX.Conditions of Approval/Reasons for Disapproval d/o), ' ' Ge rer iTi S ys i'yil 7 /occ e•.J dY-; ? e/ dcfo7/tgy/ 4116-ilo . e-ew 71 71-he 41741- r- -r air /4.3 Pec h r%/-) rrro'^ __ back— 'j 'N . 4 ttackio complete plans for the system and submit to the County only on paper not less than 11 in x I I inches in size SLID-6398(R. I ail 1)