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/3 - to/ - cx,j5-2 <br /> Safety and Buildings Division County n �/ <br /> 201 W.Washington Ave.,P.O.Box 7162 VwyK r/C <br /> �., � Madion, I 53707-7162 Sani tary Permit Number(to be filled in by Co.) <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 state-owned POWTS are <br /> submitted to the Department of Commerce. Personal information you Project Address(if dt8erent than mailing address) <br /> �P� y provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stets. <br /> I. Application Information-Please Print MI Information <br /> Property Owner's Name Parcel# <br /> 5 f Ph in • OG/Z-0/1- 0660.0 <br /> Property Owmrs Mailing Address Property Location - <br /> 3/ )jJ ihv y /31-1 Govt.Lot <br /> City,State Zip Code Phone Number /�/� r <br /> /., <br /> N�'/a, Suction / <br /> Cnwt b(i)oe / IA)T 5 ac.;G j (circle one) <br /> IL Type of Building(check all that apply) Lot H T 6 N; R I? <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of <br /> CL►/il si r a kid.) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 0 Replacement ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System . <br /> B. ❑Permit ❑Permit Revision ❑Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner S�(,�� <br /> Expiration <br /> W.Type of POWTS System/Com nent/Device: (Check all that apply <br /> l_Non-Pressurized In-Ground rePressurized In-Ground ❑At-Grade U 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(si) Dispersal Area Proposed(sf) System Elevation <br /> 950 , ,-i ll2C _ 11 r0 96.6 . <br /> VL Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanta Existing Tanks <br /> Septic osdietdmg Tank 15 or; - /) 0 1 Da i✓u,Pcl <br /> 6oNGNk f C <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature iffPfiteRS Number Business Phone Number <br /> SeCPre7 T Le,rake Zz33zz 120-W- 7567 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Pa 60c SCS LM ka / f ly N? 53551 ' <br /> VIII.County/Department Use Only <br /> Approved _Disapproved Permit Fee Date Issued I Agent Si Lure/� �,J�j'' . <br /> _Owner Given Reason for Denial S 41/6,! /^!-00(7 1 c `7Crer-_ <br /> IX.Conditions of Approval/Reasons for Disapproval [ G b 6 <br /> el.r1d- l�P1c. -air AND ?o 6� RE XP_ <br /> (16,, fE <br /> 'r. v (*v./IT QGfc...M -CEIVED <br /> Attack to complete plass for the system and admit to the Comity only oa paper not less than 8 Ds a 11 ticket ti ties JUN 0 5 2017 <br /> SBD-6398(R.01/07)Valid thru 01/09 ISCANNIIR Public Health MDC <br /> Emir onmental Health <br />