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<br /> v Y".18 rte Industry Services Division County , J f.
<br /> i ' 1400 E Washington Ave PAN'C {'
<br /> $ .� P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) p
<br /> 7! P$ Madison,WI 53707-7162
<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) i
<br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 2'7(D'1 OuN , C .
<br /> I. Application Information-Please Print All Information T i G
<br /> Property Owner's Name Parcel#
<br /> (3 W\'\ VAC)1/4.1:W IV(r S Lt-` Wan 3242%2.49M,,
<br /> Property Owner's Mailing Address Property Location off 3 b
<br /> 2 szt l co F1'e YT iM N )2) Govt.Lot `"t 11+O 1
<br /> City,State Zip Code Phone Number ,
<br /> ,
<br /> /., Section
<br /> Coll'eNL4 Cauvi= 1 IN 1---1--53 r 1 /,GXe'z5-4227 (circle one)
<br /> II.Type of Building(check all that apply) Lot# T N; R E or W
<br /> Li X1 or 2 Family Dwelling-Number of Bedrooms ' Subdivision Name /
<br /> s....., Block TOREt.E'Am lieltrt111
<br /> ❑Public/Commercial-Describe Use p E c E l' ❑City of
<br /> ts
<br /> SM Number ❑Village of p
<br /> ❑State Owned-Describe Use
<br /> DEC 132016 14 Town of S� R N �(�� I E
<br /> III.Type of Permit: (Check only one boxpt5bljpti&Sclete line B if applicable)
<br /> A. XNew System ❑ReptacemgrAiliOnle(54[Ailaitholding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration 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 /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevat on
<br /> CO C7 O O. Ca Co elb/PAW 6O,0J �t0L6 ?VW 4O j ig, 10
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units �� c 4t.. O,� .. 2 o u ?
<br /> New Tanks Existing Tanks ``. c v t o wr
<br /> g 6-Wri/4411e CC - o g 2 iZ i -g
<br /> q /� a. V ti w rn ix.0 a.
<br /> Septic oe. oldingTank i710 2. c 4' — 290-%. Came.. �(
<br /> Dosing Chamber eoo Po m P — Soo p /�(�(�`(�# // X NtO
<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 Signature MP/MPRS Number Business Phone Number
<br /> Etit c chQls tvfen.1 12 11910 608• 1018'- 31?'fZ
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> :`tS CaP&QNICv,S vim MADISON, wt S37!& --•--- _._
<br /> VIII.County/Department Use Only
<br /> Approved ❑Disapproved
<br /> Permit Fee '°°' ale issued Issuin gent.S' a e s
<br /> ❑Owner Given Reason for Denial .G, C/�` '
<br /> I.Y.Conditions of Approval/Reasons for Disapproval
<br /> ---, PtApt 06c.: '<'"), 71-t-1- lG or /-A 7E G.I / D(.r7i-.6#14 0..ay 6W , tr '
<br /> r
<br /> 04,7,-.„--Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 x 11 Inches to size 1
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<br /> SBD-6398(R.08/14) ___9 SC-0 -)( Sr7-(. /r i'1 CC.e/t "(f6- cr c-‹,4- i
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