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,_`t?-Rr!t l;, Industry Services Division County <br /> 1400 E Washington Ave ) 3/.: <br /> 1s1 ._� ,' P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 o,', t p:' �;,� Madison,WI 53707-7162 t <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 Services.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 `S I 1 Err'.'t:x i i .6-1. Li.'t7 ,; <br /> Property Owner's Name Parcel# <br /> t1/4/1i?l-=Vis Vi-1 N'ke'0l :'t er70t>-�,;l'7. t:-t I7-C, <br /> Property Owner's Mailing Address Property Location <br /> G.:-'v_>l ,..71.,%_:i t.,l t °.(,e' {Ar Govt.Lot <br /> City,State Zip Code Phone Number F. /, ' .J y., Section 1C <br /> (circle one) <br /> 1 t- (lt{ 1._11 4 tt:t} T �7 N; R rai Eors--W r <br /> H.Type of Building(check all that apply) Lot# <br /> t l <br /> 91 or 2 Family Dwelling-Number of Bedrooms i 7-1 Subdivision Name <br /> 1 <br /> Block# `' a'ut(c' 4-1c iii'i 2 p t t iV!? tI <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of MiLIGile" i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 44% Modification New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Mocation to Existing System(explain) , <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> l <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ' Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) i <br /> V.Dispersal/Treatment Area Information: I <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 740 '4 i )71.3 ✓ 1, 34"W eP) 2,ei (`.'C 7 7'i7•4`47.1' <br /> VI.Tank Info Capacity in ' Total #of Manufacturer { j <br /> Gallons Gallons Units C: _ y <br /> New Tanks Existing Tanks t c s g 8; m <br /> a U in . c s 'w' 0 G. <br /> Septic or Holding Tank it;c i M.Ai. <br /> Dosing Chamber "j<- ) —. .(I I M t:.A i ,( <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 f{ MlP/MPRS Number Business Phone Number <br /> Allele IN fylC 1"/A 'z' .lt"'C t) —1-,..7/ 1 .a1c-i0_, `r5�1 "71173 <br /> Plumber's Address 11(__Street,City,State,Zip Code) t l �r <br /> ∎-.1--V i ( ,.\'Ty {-h-..y K (.,..iP..(r Vtl,'.rzT 1 t/�1 C..7I.)h' <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ;;sued,, Issuing❑Owner Given Reason for Denial a /Ail <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> . it <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 sill Inches in size <br /> SCANNED <br /> SBD-6398(R.08/14) <br />