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WV VJ1 ...-•.1..... .II—..It.l-Lt— LI,•..,Iv.1, a,1tA V..J. . VL I,fl. 1J W UV•V. [I [ c E 11. ; IL, , I M got...44.4,1.9 ' Safely and Buildings Division County 201 W.Washington Ave.,P.O.Box 7162 /L.-. V • Ill • Madison.WI 53707-7162 Sanitary Permiitt'/Nummber(to be filled in by Co.) .�� 5 I ! q 7 / Envit car n r rC,.'r;; , :-_`}-r State Transaction Number Sanitary Permit Application In eciordance with s.Comm.5121(2).Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Noce_ Application Toms for PO D Project Address(if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for purposes in accordance with the Privacy law,s.I5.04(tXm).Slats. ere_; / Ls GL-./lA.... I. Application Information-Please Print All Information Parcel 4 Property Owner's Name 42 Z oil -o9f1 _ / g3- „It/Cc"/c. Sc!) �.),,-}5/c. Property Owner's Mailing Address Property Location 7? 3 1 H-/'. i7ri vc Govt.Lot City,State Zip Code Phone Number 5 U y., Sig) S`,Section /9 ,t G (circle one) ✓ /c�of-s So•'t / r 5 3 7 7 T 1 N; R /) C or W II.Type of Building(check all that apply) Lot t 3 t: Subdivision Name ifl or 2 Family Dwelling-Number of Bedrooms v Block ' W;4A-el et fists. K(i..t...t.. Alit,, ❑Public/Commercial-Describe Use ❑City of CSM Number ❑Village of ❑State Owned-Describe Use Town of r Sit pe • Check only one box on.line A. Complete line B if applicable) - KNew System ❑Replacement System ❑Treatment/HoldingTank Replacement Only ❑Other Modification to L•xisting System(explain) l list Previous Permit Number and Date Issued 1 B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New • Before;Expiration Owner IV.Type of POWTS System/Component/Device: (Check all that apply) Acl,Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.ofsuitablc soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Area Proposed s System Elevation Design Flow(gpd) Design Soil Application Ratc(gpds!) Dispersal Ana Required(sf) Dispersal po (i) y� 8-7 _ , y r z-re. . 1 �I z �� 9t.c VI.Tank Into Capacity in t Total 4 of Manufactwcr Gallons Gallons Units .�- j _ ei New Tanks Ex Isaias Tanks g y v '� i 4 U rn E H w 8 P. cry... lading Tank jcar'C. /aoc. i .1,1 c..c;'- - k ' Mains awakes 6r0 6s0 ' d... x VII.Responsibility Statement-I,the undersigned,assume respoosibllity for Installation Of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature M IMPRS Number Business Phone Number 1211,cl.i.....+ L.% . N Q4 INA e ,A1-..i4.- w. „),.)/6 c 64-631-SA) 2 Plumbers Address(Street,City,State,Zip Code) G 6/3 C.T1-1 ' /c 'r LA)a..-,,tr...P --j W, . S S 9 7 VIII.County/Department Use Only _ Permit Fee Dale ass Beat Signatu' Approved ❑Disapproved �J ❑Owner Given Reason for Denial .537 — 1X.Conditions of ApprovaUtteasons for Disapproval �� i F 1- :JANE_ COUNTY 4 . i ........ r' t-.; ,. ,. 4 'i 1.i:-t Attach Incomplete plan tor thespian and sabmIl to the County only on popft fol•fyss*04[Rr;-1 Iq, i"' t)D -,,P14101 Ch K. L()54 ) 0!..!i Jt1 .0` ?:!,T Y,j-t]:;NE:$1 A,fitsA\''114:1ES;tCy}i,yi i?i;S ii;rG1;N,S r, r SOD-6398(R.01/07)Valid dint 01/09 fq ex;r;SSAI3v