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/�'s1R' i County <br /> �'r`° 'TA SCANNED Safety and Buildings Division �� <br /> �a i OS + 1 W.Washington Ave.,P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 'vim PS, � 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) <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. y� <br /> I. Application Inforrination--P-lease.Print All Information 7� °r (Y �rC.) Z(01 C� <br /> Prope a prts"Name 1 f t Paz <br /> 1 1) rr': l <br /> (--,-. h r 5- c>fir C=A ,t,771")", C,,- • ..3Yz - '71(3---C <br /> Property O er's Mai'•• dress Proleify <br /> (12 d 740 t• . UnTrav1 c''�. Al Go -Lot <br /> 7 G. G-Cl��`a.:7 �j `� <br /> City,State Zip Code Phone Number ( y p` 7 <br /> e.-i_�_/•,1t.,U /., Section 7` <br /> S- �j Z.( c (circle one) <br /> i ,o le�l�j n L %y_.. T N; R lCi pr W <br /> I, pe of BuBding(check a apply) Lot <br /> I or 2 Family Dwell. - umber f Bedrooms 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ✓ ❑City of <br /> ❑State Owned-Describe Use <br /> ,,CASKI Number ❑Village of <br /> (L( W 7 jil Town of(4.flrr�s,,,/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ) <br /> B. List Previous Permit Number and Date Issued <br /> ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Sic-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 oil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (.7O(2 �' %0oa ''woo c,.2 . 7 5 <br /> VI.Tank Info Capacity in Total #of Manufacturer t <br /> Gallons ) Gallons Units 11 o'a <br /> 1 New Tanks Existing Tanks cp c u F. d d * R <br /> /-- a.J in h n i 0 0. <br /> Sepnc Holding Tank (Z co )Z-SO ( / <br /> ""-- osing Chamber Ice 75-e i / <br /> 9i/rt/1���` <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS sbowu on the attached plans. <br /> Plumber's Name(Print) Plu 's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ( c- g(' r< ',fc, , 4.,' -- ,;- 75-3` ~`` <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ✓ Date I sued Issuing gent Sign. <br /> ❑Owner Given Reason for Denial $ /Fej, <br /> IX.Conditions of Approval/Reasons for Disapproval ; <br /> --------FEB-r/ 3017 <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inaliblicsHealth MDC <br /> Environmental Health <br /> SBD-6398(R.1l/1l) <br />