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�TMr <br /> /.�—�y Industry Services Division County <br /> iit 1400 E Washington Ave [�a►- �"yi <br /> /? , 1 P.O.Box 7162 Sanitary <br /> 131 �. , i terry Permit Number(to be filled in by Cok <br /> y., ,-. )E /:; Madison,WI 53707-7162 <br /> � <br /> ��{ r;_�0/C•� Doan-1 <br /> \r3110YN <br /> Sanitary Permit Application State Transaction Ntnnber <br /> In accordance with SPS 38321(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 Lawis.15.04(1)(m),Stets. <br /> I. Application Information-Please Print All Information D CKen Rat4 <br /> Property Owner's Name Parcel# <br /> Nate. Rl,tsch p, 161 ycey I.Iett- 050ty-044-BTC o-© <br /> Property Owner's Mailing Address Property Location <br /> 5441 T- ttT or Pr Govt.Lot <br /> City,State Zip Code Phone Number tJ VJ , , <br /> /.,SE /., Section <br /> (circle one) <br /> I�ti�C11. C11 LJ I / T S N; R 1' E=IX <br /> II.Type of Building(check all that app'iy/� / Lot# <br /> fif 1 or 2 Family Dwelling-Number of Bedrodms / 1 — Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 124' 97 Town of Perry <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. oNew System ❑ lacement System ystem ❑Treatment/Holding Tank Replacement Only 0 Other Modification 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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ErMound>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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i'CC' to I COO 1225.5 'V .O r 1 q 7.0/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ;g <br /> New Tanks Existing Tanks w n y '� 2 § t» <br /> ais rnV, ti wC7 a <br /> Septic os iividing Tank I2saZp — I Go I M EADE K <br /> Dosing Chamber le leS i I M E04/ - K <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 hi MPRS Number Business Phone Number <br /> k'k-Ielt W. hAelniAcgt �— CA-.> , oats 831-8#0'3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 313 Ccxh-rty 1-‘*y k to itinakee, W1 55S97 <br /> VIII.County/Department Use Only <br /> glpproved ❑Disapproved Permit Fee_ Date Issued // g i W*3---)❑Owner Give n Reason for Denial $ `� �+ Z i 7-20! _ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �k ' <br /> eiZa <e-7 /j1Pwvo t`fr'70,m SI T� /f�,y�� , /s/f/.��. �m FEB <br /> �J�Pc f/'l (l' / 744` ��0I !(M T. • Ot� -7 ' D 16 20 8 <br /> FOIL Co�ryp,�-c�4,,, r L �� D G �QQ y c:1.../14 <br /> � �`�� �" `a Public Health MDC <br /> Attach to complete plans for the system and submit to the County only on paper not lass than 8 in x 11 inches in sipq,v f r c sl m e n to Health <br /> SCANNED <br /> SBD-6398(R.08/14) <br />