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�s.,,eetcnrr h� County <br /> I Industry Services Division aop <br /> 1400 E Washington Ave Sanitary ermit Number(to be filled in by Co.) <br /> I`; P.O.Box 7162 ry y <br /> ;.�; ' _ r:` Madison,WI 53707 7162 <br /> q, _ _ ..`.;if <br /> / 3-• aof Doc <br /> `.�rac�p�e� , <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information �((� <br /> Property Owner's Name Parcel# C t( — ? –<) ' I <br /> /...)% ce.,,t,. 5t-- F I L C- oy6/P-G((- ts, -Py1-° <br /> Property Owner's Mailing Address Property Location <br /> 1 1 V`> '/ o r 1,,,,,x. J?) _ 12-41 Govt.Lot <br /> City State Zip Code Phone Number ft‘-'A, Section <br /> ) one) <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ i or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 14 Public/Commercial-Describe Use •sir 5 , /7�.J"t a---. Block# <br /> ' ❑ City of / s <br /> ❑State Owned-Describe Use <br /> CSMNumber i P -J-- '/f' r <br /> III.Type of Permit: (Check only one box oif)ine). Complete line B if applicable) <br /> A• <br /> 711.New System 0 Replacement System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision . ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 1 Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ,[]Non-Pressurized In-Ground ❑ Pressurized In-Ground El At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> �(Q�Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application, Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ,7 o,2,, Rate(gpdsf) - <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer al o u t . VI . <br /> Gallons Units <br /> New Tanks Existing Tanks / a- U in N t/i ii V t3- <br /> SrTpi c Holding Tank /o Zv,9 C as 1-61 KC •• tLo ; ❑ ❑ ❑ ❑ <br /> Dosing Chamber I ❑ I ❑ I ❑ ❑ 0 <br /> VII.Responsib' 'ty Statement- I,the undersigned,assui responsibij(ty_for-instsllatlon of the POWTS shown on the attached plans. <br /> PI <br /> 6isb <br /> er s Name Pri t) pi if tgnature MP/MPRS Number Business Phone Number^ <br /> Plum 's Address(Stree 4 ity,State,Zip Code) <br /> U Itri) 710 CI�y� �� ,_ �2 53�r'�5�' <br /> Z` <br /> VIII.County/Department Use Only - <br /> TApproved ❑ Disapproved Permits J ee _ G• , Date Issued Issuing Age ign a ,mot _ <br /> ❑Owner Given Reason for Denial $ 835- - ^- 2 $-2' 'Q ` 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the s stem and sub q�.�oyy�� ��yy�� thin 8 if2 x 1 t toe es to size <br /> p y tl./is°1��1 . <br /> SBD-6398(803/14) <br /> t <br /> 4 <br />