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.� '� County i <br /> /4.7 --'\9:\ Safety and Buildings Division `JI i <br /> A I, ,y ,;,,,. *, 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> v, *; Madison,WI 53707-7162 <br /> < j 3 14 — 00 3`7 t-f <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),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 address) <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(1)(m),Stats. <br /> I. Application Information—Please Print Al Information 4'n7 n v� V A 1Wd 9L <br /> Property Owner's Name Parcel# <br /> ill C Crto i'vn art. O 51 O . 30",-8atte---9 <br /> Property Owner's Mailing Address / Property Location <br /> 3C 0' J3 5 4 I f" L A— Govt.Lot <br /> City,�/State Zip Code Phone Number NE y,, s w /, Section 3 0 <br /> a ti,61 t5a". W.r 537 II circl one) <br /> II.Type of Building(check all that apply) . - Lot# T s N; R r W <br /> 1'or 2 Family Dwelling—Number of Bedrooms( ,' / 1 Subdivision Name <br /> ''. —_—.--/ Block# Mt' <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> 0Cg63 W.Townof AJ+ <br /> III.Type of Penn it: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Exis ing System(explain) <br /> r•R Co on Pte C. <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner 87-Ot f 7q 8-4(-/9€7 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) etc)Qas <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 ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: 5-7C/J 2jt(a. PA47,y.' 1L,O <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> L tco - 1 2-71. 6-xt S'i 4'.?0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o z y y o <br /> New Tanks Existing Tanks '�-' c :: .g A .2 * j <br /> g U iii rn w 3 P. <br /> Septic or-Melding Tank 19.5O 12 sz ( a�` I. V . <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,ass me responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb s Signature �{),1,., D y, MP/MPRS Number Business Phone umb r <br /> ,e'• IOC)6 Y-e- ` ` ,. �.X4i Air 4 0 e P -7'99 r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /o ,., "7"/ ) 73100 C'i-- . yr7,`6•1 ah • S?7/ __•__ <br /> VIII.County/Department Use Only _ <br /> Je.:J proved 0 Disapproved Permit Fee ...�- Date Issued Issu' Ag t Sign ture 0 <br /> $ P 3---.) 12-C:P2t/6 c <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disap royal <br /> 1E—C°\( 7 NFW f a c SE -6 �`-fr-( � .-......... d"74,fT� _. <br /> Ema.1 ; g.-. Jr aoc� tai sae, CAP Si t ., l (r i 1 i ns <br /> Attach complete plans for the system and submit to the County only on paper not less than 8 I/2 x l Inches in size <br /> SBD-6398(R. 11/11) <br />