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RECEIVED <br /> %�""'L�;, - county&hog^ <br /> 71jj ��r APR Q 4 2016 Safety and Buildings Division ,� <br /> 'kr`0'*'�� ' 201 W.Washington Ave., P.O. Box 7162 <br /> s g Sanitary Permit Number(to be filled in by Co 1 <br /> ■ �s:PS' /. Public Health MDC Madison,WI 53707-7162 <br /> •'` �% Environmental Health 1 _2 6 /4_ c hO68 <br /> l ! L1 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance.ant SI'S,383 2 1(21,Wis. Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note Application forms for state-owned POWTS are submitted to • Project Address(if-different than mailing addre;>:i <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats. (J `�y�• �' <br /> I. Application Information-Please Print All Information tr/ 1 1(�{ - <br /> Property Owner's Name -- Parcel# <br /> �Awlannk M c, Io e, 6 --0 0g07 _/aq-3o12-0 <br /> Property Owner's Mailing Address Prop rty Location <br /> 73 77 -&cur Cf.,sd- b!`ve, Govt.Lot------ <br /> City,State I Zip Code 1 Phone Number 6 <br /> _ Sccuen _ <br /> .�tkK 0t t'ty 1-.141:-. <br /> �3 (�D _ ) J—Z.3 et/ I (c;r;lc and <br /> C , <br /> II.)ype of thudding(check all that apply) ` -- LA <br /> I ;! I or:: 'amity Dwelling• Number of Bedrooms d : 1`. Nam <br /> —_ <br /> ^ <br /> / Block# 114 l L iirtia l( h e t dS <br /> ❑Public/Commercial-Describe Use <br /> - _ ❑ City of - <br /> i <br /> (J State Owned-Describe Use CSM Number ❑ Village of <br /> Frown of /0. Ur(- <br /> III.Typeyf Permit: (Check only one box on line A. Complete line B if applicable) <br /> A </J -1 <br /> .J New Srstern 0 Replacement System I ❑TreatmcnUHolding Tank Replacement Only > 'r Modification to existing System itrplainS <br /> e c vzinect <br /> B. ❑ Yenmt Renewal ❑ Permit Revision ❑ Change of Plumber I List I'revious Perm::Number and Date I•siie 1 <br /> ❑Permit Transfer to New <br /> Licfore Expiration i Owner <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 /> O Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> - <br /> Design Flow(gpd) Design Soil Application IZate(gpdst) l Dispersal Area Required(at) I Dispersal Area Proposed(sf1 System Elevation <br /> _ I <br /> VI.Tank Info Capacity in Total ! t1 of Manufacture! I - —r--1 <br /> c I <br /> Gallons Gallons 1.;,,,,s ' o f _ <br /> New Tanks ' Existing Tanks I ' 12 I J = .J i ` <br /> Scnii...r liht(bing Tank I <br /> I t . I <br /> Dosing Chamber I <br /> I <br /> VII. Responsibility Statement- I,the undersigned,assume re,.,nsi.T for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Si g ,+t-re MP/MMPRS Number Business Phone Number <br /> �' r f <br /> M-- (; ! /`� 1. A , / 02093 _ 603 _ca_25`. <br /> I_Plumber's Address(Street,City.,State.Zip Code) _ <br /> )�7�'` v4..i,ra (1(, Vic , 1,�j7 <br /> S 3SS°7 8 <br /> VIII. County/Department Use Only <br /> O Approved ❑ Disapproved n Permit Fee �_.. ' Date Issued Issuing _ -Signature <br /> ❑Owner Given Reason for Denial , .J'7 ae0C/0/6 ��//i�� ✓�/./�. <br /> IX.Conditions of ApprovaVReasons for Disapproval / <br /> 1.Or,/2GG74i�i'7 eu/S/ �•��*an/r/ S1.Si� ", ' ` 3 �/� rc� '"T�y.9jL <br /> 41C.- /14Sir‘--A9 tit-o/- ,�a hock1:-/li.J <br /> _____ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a 11 inches in sire <br /> SBD-6398(R. I I/11) <br />