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l <br /> /' sr County t <br /> /� �e, Safety and Buildings Division r** <br /> of; D�...%,,T� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by C . ' <br /> \4, p Madison,WI 53707-71621 � � <br /> �r� l S-'��r 1 <br /> ��;Yn,,, <br /> rwL Sanitary Permit Application State Transaction Number <br /> P In accordance with SPS 383.21(2),Wis,Adm.Code,submission of this form to the appropriate governmental unit <br /> .oLA� 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 Servics. Personal information you provide may be used for secondary Q� <br /> purposes in accordance with the I'rivacy Law,s.15.04(I)(m),Stats. IOW Ta'� 1;k/6e4 & g <br /> I. Application Information-Please Print All Information _r <br /> Property Owner's Name Parcel# <br /> �U 1 1 E- Sly E I)c 3 oe(Z�,�S�" QS-f�—2 <br /> Property+Owner's Mailing Address r Property Location <br /> `'{ OLI� �Z7tyJ f2� L 1 V �c� Govt.Lot 3� <br /> City,State Zip Code Phone Number <br /> p (� �- t_ (� p r� NW /., f� /+, Section <br /> im Pkgs4 lA(1 ) Li�r-t-• J�CJS l �o 'J'TJ'6- i O 1 (circle one) <br /> II.Type of Building(check all that apply) Lot# T € N; R (� �F r W <br /> Lor 2 Family Dwelling-Number of Bedrooms ft Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ,Mown of AlEDfN$ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System ❑Treatment/Holding UHoldin 8 Tank Replacement Onl y 0-Other Modification to Existing System(explain) <br /> ) <br /> gE-comeEc-re,et <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New VI Sg4� 7y ��/ <br /> Before Expiration Owner gg„ �/ (9 <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) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s0 Dispersal Area Proposed(at) System Elevation <br /> ' VI.Tank Info Capacity in Total #of Manufacturer <br /> k.‘. 8 <br /> Gallons Gallons Units .o ti o a 22 <br /> V New Tanks Existing Tanks ,m c % E T iii <br /> Septic or4tolding Tank �.� /�€ /287 D�LMR y <br /> Dosing Chamber r• I n/� r76dI , _ DA/ 4Q�-y p/ <br /> Statement-I,the undersigned,assume responsibility for installation of the shown on the attached lane. <br /> VII.Responsibility g P IY P <br /> Plumber's Name(Print) Plu s Si nature )MPRS Number Business Phone Number <br /> \\ ` Plumber's Address(Street,City,State,Zip Code) <br /> rInaA.----- <br /> 30 8 In EA1)cxs,1.-flRIZ C i24.4 Ca DE Rs=Mki 5353 <br /> VIII.County/Department Use Only <br /> Permit Fee .1,, Date Issued Issuin Age t Sig ature <br /> Approved ❑Disapproved S�S� " <br /> ❑Owner Given Reason for Denial (3-14-246—2c1 < 11- . s'ar V <br /> IX.Conditions of Approval/Reasons for Disappr 7 vat <br /> 70 REP E hC(frt f f' J 4 /Yet,' ©^ ei 4/1-O <br /> RE"64/`Ik"Ec f r ' (f-)t:/f9iAtt, fie( - r ,4c fri7"•c h r <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In s I I Inches In size <br /> N WRrre 15� ct- .ire r° ei cf oPo+v, 4/ r;e rweF2`( <br /> SBD-6398(R.11/11) <br /> f 4gM tr -rtfri W(ci-Dan/ 4,-4D ft 7 A ,r ; A/Ct'c. 4C47a!9- 'frgDf 4' <br /> 4/YP ,D4-✓Y Cowl(ry <br />