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Ma"" +; Safety and Buildings Division County �J�/ <br /> i `'"y 201 W.Washington Ave..P.O.Box 7162 0�. . COUNTY c.J <br /> Madison.WI 53707-7162 <br /> (� sp K.. Sanitary Permit Number(to he tilled in by Co.) <br /> vl s5 <br /> \,$1Os4 3 ao,�_ ��8g <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2).Wis.Aden.Code.submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ,2S–,.9, 0rc<r►r ,'" ve,)1 ey Rid• <br /> purposes in accordance with the Privacy Law.s. 15.04(1)(m).Slats. <br /> I. Application Information–Please Print All Information <br /> Property Owner's Name P�ccl# <br /> 4XD,'1'■ 4 Cron •Ir Y <br /> OS0(J -3)(- 9 l/0-1 <br /> Property Owner's Mailing Address Property Location <br /> • <br /> 300 'i);'s,lNArv.t.•'∎ Vc.11,t7 mac, <br /> Govt.Lot <br /> City,State Zip Code Phone Number /...,./5' ,✓ y,, jiff' y,, Section 3 <br /> 't't)-. NoPeb t....),S. • 1. e6,Off�.f23 ' `7t0v;,� T S N: R 6(circl re) <br /> H.Type of Building(check all that apply Lot# <br /> ❑I or 2 Family Dwelling Number of Bedrr ors Subdivision Name <br /> Block ii <br /> ❑Public/Commercial–Describe Use <br /> ❑ City of <br /> ❑State Owned–Describe Use CSM Number ❑ Village of <br /> [3 Town of Per-ry <br /> III.Type of Permit: (Ch ' y one box online A. Complete line B if applicable) <br /> A. <br /> ❑ New System ®Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> -B.• ❑ Permit Renewal ❑-P »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 a 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 SoilApplication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> � o a t// 3�v (Sec 3 o t!3(.� <br /> VI.Tank Info Capacity in /total ti of Ma ufaeturer <br /> Gallons Gallons Units u <br /> l° <br /> Ness'tanks Existing Tanks 'g e U c' <br /> - c .L.. V J J tt 7 <br /> c C � s _ <br /> 0.. 0 Cr: v; ii C7 i= <br /> Septic or Holding Tank <br /> 1 orJ `— f DC U i pa_l r.-.L,r cL/ j< <br /> Dosing Chamber e) <br /> 1 pc,1 1^n.e.,r el../ <br /> VII.Responsibility Statement– I,the undersigned,assume responsibility for' stallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb/:".Signal - 1 MP/MPRS Number Business Phone Number <br /> 301...-■ I4 pcie•11 4i - Pi 2 /God) —76 7— 3 Y6 <br /> Plumber's Address(Street.City.State.Zip Code) <br /> /, <br /> \ II.County/Department Use Only — <br /> proved ❑Disapproved Petmit Fee Trench $475 Date Issued Issuing A em Signature <br /> [r[r ATG.Mound,HT S 525.00 <br /> ❑Owner Given Reason for Denial Reconnect 520p. �� - � <br /> - IX.conditions of Approval ?sons for Disa tiPv -- --- �- - <br /> APR 0 G 2017 <br /> b� C v \ <br /> Health <br /> SCANNED Envirotnmental1t-loatth <br /> Attach to complete plans for the system and submit to the County only on paper not less than ti l'2 x 11 inches in sin <br />