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� y.SriL'ryy - con y <br /> $1" °Q , Safety and Buildings Division <br /> i IDS 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 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. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> A- L I'c-k .—c- 07oC/.:23/i-/ So/( <br /> Property Owner's Mailing Address Property Location <br /> [ 1 7 'S L C.,VI ER e'S E Govt. of <br /> City,State ip. q Phone N ber Govt. <br /> , , <br /> ,A � t, j� C� �+ / 17/.,��. /,, Section <br /> U vok— ∎-Z / . 'S3 j 6c.% 11 ' (c� on W <br /> II.Type Of Building(check all that apply)1 Lot# !II T N; R <br /> YP g( pp Y) J _ <br /> or 2 Family Dwelling–Number of Bedrooms r J Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial–Describe Use <br /> ❑City of <br /> ❑State Owned–Describe Use CSM Number ❑Village of To �. -- _ <br /> wn of n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ' ,ksiew System rPrr ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0 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 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground .t--Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) lL.t�AN -t ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Are equired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7--S o 0' c, /, ;2 4 2-6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L' o o <br /> New Tanks Existing Tanks w o d "y+ _ <br /> GG U in co) w 0 a <br /> (—8- <br /> pti�Holding Tank t t c)� 1 Loor `_ n. j f . <br /> Dosing Chamber f k1 y"`�`a+' /` <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS sho 1 the attached plans. <br /> Plumber's Name(Print) Plu.•,er's rgnatur / MP ar..-: umber Business Phone Number <br /> . ,Z7....357 '7 Go: 9 '7,23 <br /> Plumber's Address(Street,City,State,Zip Code) �� <br /> LliSS'6 C--C),, L,1 ' 1\ c.. L- -- - .3 6 s <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved Permit Fee Date Issued Issuing :-i atur <br /> $ <br /> /< 11. , <br /> ❑Owner Given Reason for Denial 7 , <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 8 1/2 z 11 inches in size <br /> SBD-6398(R. 11/11) <br />