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i f <br /> 3`""'�� , Safety and Buildings Division County . j <br /> (s‘111$ , l 201 W.Washington Ave.,P.O.Box 7162 vt,►�t? h/ <br /> i• S iV Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> I S—20ib -- 00 1'0-7 <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 /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information RECEIVED rAi r on.,( Rd. <br /> Property Owner's Name Parcel# <br /> 015on R '" 671 Z Z S� S S 500 <br /> Property Owner's Mailing�Address 12 Q OCT 0 3 2015 Property Location <br /> I D68 i4 I' vy 12 ' 113 Public Health MDC Govt.Lot <br /> City,State Zip Code Env re4ma bia0Heaith NW /, 54- 'A, Section Z3 <br /> DOr Pe id 5 3 5 31 (circle one) <br /> II.Type of Building(check all that apply) Lot# T -7 N; R t'Z6.-or 2 Family Dwelling-Number of Bedrooms / 1 Subdivision Name <br /> Block# <br /> ❑Public/Comrnereial-Describe Use <br /> City of <br /> State Owned-Describe Use CSM Number ❑Village of <br /> 1 Town of O /� <br /> t?r-ti`t <br /> III.T of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System 0 Replacement n Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. ❑Permit ❑Permit Revision [J Change of 0 Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> 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 KiDther Dispersal Component(explain) Pretreatment Device(explain) <br /> V.DispersallTreatment Area Information:g Tai <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area s Proposed p (t) System Elevation <br /> 6 o a I 54 0 15-ao 5,er f,k PlAA-7 <br /> VL Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septicor}Ielding Tank , 3 DO 1 t o , 9e't(Wens n O HC/Pi Dosing Chamber <br /> 140 -.. 150 Trtek <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 Si 411P/MPRS Number Business Phone Number <br /> 3t'Ad T I�vake �!� '/ _ it 37 z Z 920-ear 75`0 <br /> Plumber's Addfess(Street,City,State,Zip Code) <br /> ?.o, Box S6 8 Lake /t'i'lls t4i 5 3�5/ <br /> VIII.County/Department Use Only <br /> r` <br /> Approved = Disapproved Permit Fee Date Issued Issuin nt gna C <br /> Owner Given Reason for Denial $ a.1'2 1 /„'- 2 p/G <br /> IX.Conditions of Approval/Reasons for Disapproval t'3 1 <br /> r5i. k</e R&°'1, celWeN( Aqmign/41— -f( < /ha 1� <br /> tine- gD ry 17.1 /(4 7q1,4-f___ (o (7 /?_ 11--c1 7 X-c r c-"(--(- <br /> (t1 '-./G c v/1 2,y r 4ac_ -cdive'��4 4�D / -0164-c - q6 <br /> Attach to complete plans for the system and submit to the County only on paper not less that'll rn z 11 Inches In die <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />