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1 it 11 j MI AR 2 2009 ;k1! commerce.wi.gov Safety and Buildings Division County -201 W.Washington AVC.,P.O.Box 7162 � � 8 Madison,WI 5 3 7 07-7 1 62 Sanitary Permit Number(to be tilled in by Co.) Department County �3 ) Departmortt of Commerce Sanitary Permit Application Statc/T�ran�sactionNumbcr q In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ��"" (v �` unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc Projcct Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. V b le.,,,,, I. Application Information-Please Print All Information Property Owncr's Name Parcel# �I J- 1�__Lc/ e(.-%--an/ 00 07— ,2-6, - - 9/76 — O Property Owner's Mailing Address /� (� Property Location �s /SW/ '3 5 w, go, Govt.Lot City,State /^ ✓ Zip Code Phone Number / S La y,, /V L y., Section o l? - -� / 15 1/45-3r7...-/- J 7 7 — top �j (circle one) — T N; R 1 E or W II.Type of Building(check all that apply) Lot if / A1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name _._._ Block# ❑Public/Commercial-Describe Usc ❑City of ❑State Owned-Describe Usc CSM Number ❑Village of // 96, 7 51Townof Serl't5c(c.le- III.Type of Permit: (Check only one box on.line A. Complete line B if applicable) . • A. yifNcw System ❑ Re p lacement S y stem ❑Treatment/loldin g Tank Replacement Only 0 Other Modification to Existin g System(explain) B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS System/Component/Device: (Check all that apply) ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground EAt-Grade ❑Mound>24 in.ofsuitablc soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation J , 4S, _ b —7,S 0 q D GrGCA-n 9 con*vi z:4.S VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units fd. s° U to New Tanks Existing Tanks o E 2 ii 2 2 2 a.U in N vs it t7 P. Septic oriisieting Tank v 0 o / J 1 J.'eG _ \C Dosing Chamber ,' s b 6,c- / ✓ - / VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Namc(Print) Plumber's Signature M4'IMPRS Number Business Phone Number Ae- ,+ e.-0-.. (4-) L . H e-el.L>.. 1 z ,__ ¢—t_._jz --.6/6 s" S 3/—eft o 3 Plumber's Address(Street,City,State,Zip Code) Cv13 c %t-( '' Ic " WG-....`1.`z. / yr , C 315 ) . VIII.County/Department Use Only Permit Fec Date Issued Issuin germ(. natu Approved ❑ Disapproved $ 180 p V--O ❑Owner Given Reason for Denial / • IX.Conditions of Approval/Reasons for Disapproval ----, fe& PQ k Tf fi /4tcE 'r ,4/1. IN GRANTING THIS APPROVAL, DANE COUNTY ENVIRONMENTAL HEALTH DOES NOT HOLD IT. c' L{RDL�� f ,., till ch to complete plans for the system and submit to the County only o of t f i I A sih liNen-AN6 OH SNE�-1. :�r1- DS _ 'a j�2..._ �� , MISSIONS,EXAMINATION OVER- SIGHT, CONSTRUCTION OR ANY DAMAGE THA r opt SBD-6398(R.01/07)Valid thru 01/09 RESULT IN OR AFTER INSTALLATION AND RESE.ii jj THE RIGHT TO ORDER CHANGES OH ADDITIONS O "K r. � /"]a i I SHOULD CONDITIONS ARISE MAKING THIS v' NECESSARY.