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1 ' , , p ECEI1 ;W ip;\,;I <br /> Al 1 I ��1 <br /> 11: 'i !;! <br /> •` ' erce.w.gov i -' Safety and Buildings Division County <br /> 201 W.Washington Avc.,P.O.Box 7162 •� � <br /> a.l <br /> i f.--4 Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> c r1 ✓ri----- / sag oaa <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for statc-owncd POWTS arc Projcct Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> u .,scs in accordance with the Privac Law,s. 15.04 I m,Slats. _AU.Gl/G(/.c Pc:k,ss <br /> 1. A lication Information-Please Print All Information ` <br /> Property Owner's Namc Parcel q- <br /> 3;<< C.. Zc. 0iew_5/C.. Oly- 6810.- 0aa- 0,259 <br /> Property Owner's Mailing A,dross Property Location <br /> 3`s 7°). ./4r aLre S P,-SS Govt.Lot <br /> City,Statc Zip Codc Phone Number /))/ y,,iUt. y., Section �- <br /> 6-(cv., ea..'!,.� t.t);- �7 35-`)C, __ (circle one) <br /> II.Type of Building(check all that apply) tot q T 8 N; R J E or W <br /> 1 or 2 Family Dwelling-Number ofBedrooms // c y Subdivision Namc <br /> Block q 6 e,kr(c.t-,S j -t,„ 1 I <br /> ❑Public/Commercial-Describe Usc <br /> ❑City of <br /> ❑State Owned-Describe Usc CSM Number ❑ Village of <br /> 0 Town of Pwr14-e- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ill�:; New System ❑Replacement System ❑Treatment/Holding 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.T c of POWTS S stem/Com oncnt/Device: Check all that a I <br /> ':e Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade` ❑Mound>24 in.ofsuitablc soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Componcnt(explain) ❑Pretreatment Dcvicc(explain) <br /> V.Dis crsaVTrcatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(si) System Elevation <br /> (add el /S')J /.5-/2_ 97. f73�y7. / <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units 2 e'a u v 2 <br /> Ncw Tanks Existing Tanks in y <br /> a�.O in t r w 0 0.. <br /> Scptic or Holding Tank / 2 Sc.. /20e, .a e c c�.- x <br /> Dosing Chambc: / .5-‘' 6..s. J / <br /> ■ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Namc(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> e_� (J . 1 .Q-1, �...i2 ' Q w, aa-o/6 S 6Og-g31-I/0 3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 5( 3 C -nt- '/c `` L,sc,,,-,_G c_s_), . • 3&-5 7 . <br /> VIII.Count /De artmcnt Use Onl <br /> Permit Fee Date Issued Issuin df nt Signature <br /> In pprovcd ❑ Disapproved D <br /> ❑Owner Given Reason for Denial S-3i37 6-/3-0u . <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 a 1I Inches in size <br /> 1l3 - ayq I 0 ehK-- y,q,ii <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />