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o. Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 bo w� / 4 <br /> �=pg' '� SCANNED Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 13— to t b — 00 310'7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Imposes in accordance with the Privacy Law,s.15.04(Ixm),Slats. RECEIVED <br /> I. Application Information-Please Print All Information rA I r CJa J . <br /> Property Owner's Name Parcel# <br /> 015011 r. Parcel 671 Z Z 31 SS 500 <br /> Property Owner's Mailing Address OCT 0 3 Z016 Property Location <br /> /De? a PK/ 12 a /8 Public Health MDC Govt.Lot <br /> City,State /► Zip Code Env ri m HeaIth NW %., $ ' , Section Z.5 <br /> �t-Po Q / 1� 5 5 ,31 T N; R (circle one) <br /> H.Type of Building(check all that apply) Lot# ` <br /> 11 /ZC <br /> or 2 Family Dwelling-Number of Bedrooms �/ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> k 1 Town of er r Id <br /> III. of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System ❑Replacement ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. El Permit ID Permit Revision ❑Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration - <br /> tType of POWTS System/Component/Device: (Check all that apply _ <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade b Mound>24 in of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank i� Component(explain) Pretreatment Device(explain)3' <br /> V.Dispersal/Treatment Area Informaation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> 6e8 , W - 1 5-0 0 1 Tao 5et s,t Pi 7 <br /> VL Tank Info Capacity in Total #of Manufacturer Mahal <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks t� <br /> �..JkWagTank ) 300 1 '5Ob / 1Vtttlie tai eencriqi <br /> Doing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S',, ,., *'/MPRS Number Business Phone Number <br /> iif y T Le yoke \ v c <br /> � Y 2 r 37 7 Z 4,20-10- 7 r <br /> Plumber's Address(Street,City,State,Zip Code) I <br /> 9.O. 80, 5.C . Ake /f/14 k S 3455/ <br /> VIIL County/Department Use Only 4.6744___ <br /> Approved _ Diner Given $ L4 3e Issued I t gnu C <br /> _Owner Given Reason for Denial $ L{3 /4-6-261.6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ri,V(40 R ,/.-4(46eet AAMV4)/A.1 ‘41.0( -(tp frat7i ,,ec- <br /> ((?E- Pow-- (—i i9- q .//D /t 17C.4Z 144ç <br /> Attach to complete pleas for the system and mark to the County only on paper not leas thah a in x It Inches in ds. <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />