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/ir ln,Vr�n ..�) �_. a 'y --- ---._-_..._. Intlu"sitty Services Division County (Or 1 1400 E Washington Ave ID�..h`-c. JrY1 ; 1. $ - P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) �y\� Madison,WI 53707-7162 V� ._: , I e3- o I too 307,0 '�,fs..•iv,.r,, Sanitary Permit Application Statc'1'ransactionNumber In accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit 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) the Department of Safety and Professional Services.Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I. Application Information-Please Print All Information Property Owner's Name Parrel# ._ 3 CLL4)n t $a.tr\c: _,--0, OX.hl'i0v� � �� —OCnCXt�'v�53' SSc,_t Property Owner's Mailing Address Property Location [�_,- DEC 19 2016 p y 2 .� . • O\IA L( ' J tr Govt.Lot City,State Zip Code i Phone Wikjiealtt-1 . ,,5E_. �''-`5 1/4 , Section Health \O 1 1-\ V 3 _h I ii 1r r"\ -2- (circ on e) T UCo N; R ®.rW \I_I�.Type of Building(check all that apply) ) Lot# `ld I or 2 Family Dwelling-Number of Bedroom Subdivision Name ///�� /� Block if /'sJ I A ❑Public/Commercial-Describe Use .-/ NI)ft ❑ City of CSM Number ❑ Village of ❑State Owned-Describe Use {(�'� n n X74 2 C7°1 `Town of 1,3 i (-CC.- DGt+)Oen III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) CO)hhC°( -4 _t-D,5l hlrrvl B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner --'-> IV.Type of POWTS System/Component/Device: (Check all that apply) ❑ Non-Pressurized in-Ground ,Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil IKMound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) Cj V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 4 5O o ' -1-S U L l t-2 /00 ,3 ee.t- . VI.Tank Info Capacity in Total #of Manufacturer Gallons_ Gallons Units u d$ o New Tanks ( Existing Tanks�) o a __... ._. a.U in m rn u, 3 a Septic or Holding Tank i 000 v) / / (ZC 57- X Dosing Chamber VII.Responsibility, Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plmber's Name(Print) Plumber'. 'n re MP/MPRS Number Business Phone Number 'CLUBone�l Inc,. -- - - - -r-- b eaz-).. - (( ; )z49b- -h-yr) Plumber's Address(Street,City,State,Zi Code) 2 f _ • __ r. 0 ci.l 6O vi, 1 ..5-5 A ) . VIII.County/Departnik t Use On y I _ Permit Fee Date Issued Issuir Aget -4 !not s�6�^ droved ❑ Disapproved ^� Al/❑ Owner Given Reason for Denial $ ` 1p? 20/' IT 1 I '.Conditions ofApprovaUReasons for Disapproval '�?A - ` 1 1�.�- ` 1 nn { �rSl ,� 0 �tt�-� lV a� Atinch to complete plans for the system and submit to the County only on paper not less than 8 iti x I t inches in size SBD-6398(R.08/14)