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',/,.+-y*ml�i County
<br /> /0 • Safety and Buildings Division b; &A
<br /> tfi`0$ ` `,,. � 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by o.)
<br /> • P = Madison,WI 53707-7162
<br /> c $ / I
<br /> State Transaction Number
<br /> Sanitary Permit Application
<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 All Information
<br /> Property Owner's Name Parcel#
<br /> °f,CI.sde.:�A.<., V.,,, ,,( -‘1,.,s'.-,es. 6,,L-tise -c o t.)55 - )s3--`) 'S1)-0
<br /> Property Owner's Mailing Address Property Location
<br /> ?i..l �X; (4,l a so 5
<br /> Govt.Lot
<br /> City,State Zip Code Phone Number r f�j i,,.' /,, try y., Section . s
<br /> M•ct���,i t/ - -S'SZ Z CeVs-13.3- Lt/.9/ (circle one)
<br /> H.Type of Building(check all that apply) Lot# T N; R E or W
<br /> ❑1 or 2 Family Dwelling-Number of Bedrooms V Subdivision Name
<br /> D .„ Block#
<br /> pil Public/Commercial-Describe Use*)750 -1.111 l fl4eL,u ❑City of
<br /> Sinn. ty
<br /> ❑State Owned-Describe Use 67 FA-049a. palt414r4 CSM Number ❑Village of
<br /> 32)O I-Town of ..st)a7 `-( `4--Lel
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) \J
<br /> A. ❑New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain)
<br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber
<br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner /.7.-Z9/3— °WS-7
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply) /
<br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ait 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> 14s5`-) . .3193 Li sod 99,t,rs too,is /to,J i
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units n u U o
<br /> New Tanks Existing Tanks 4d a ,, u `�
<br /> &`_U i.' t ti w t.7 a
<br /> Septic or Holding Tank 30 0 S-300 3 6-1-4 k ,
<br /> Dosing Chamber /000 /y,V 1 i• k
<br /> VII.Responsibility Statement-I,the undersigned,assume esponsibility for install tion of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plu•* 's Si i re MP/MPRS Number Business Phone Number
<br /> JOhaT 1t0ill J¢,,9 10"1 IF/ i/t - 56161014 P- t31-01)742
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 6$\5 CI W wfiwvt, Y t i r VI 53.513i
<br /> VIII.County/Department Use Only
<br /> ❑Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature
<br /> ❑Owner Given Reason for Denial
<br /> $ "7
<br /> i.
<br /> IX.Conditions of Approval/Reasons for Disapproval r
<br /> . 1E
<br /> APR 1 2011
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x II inches in size
<br /> Public Health tdl)C
<br /> Environmental Health
<br /> SBD-6398(R. 11/11)
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