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• <br /> • <br /> -5 County <br /> Safety and Buildings Divisionne� tilt.„ <br /> • .11i.-.-„ , • 201 W.Washington Ave.,P.O.Box 7162 San; <br /> (P 1, ; j Madison,WI 53707-7162 <br /> �'Permit Number(to be filled in by Co.) <br /> -�_=.1.- /3-ao,,- 00 3s3 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. <br /> I. Application Information-Please Print All Information n' r te • <br /> Property Owner's Name Parcel# <br /> Vey' T-6Y 's 0-70 052.2-11.43- 0 <br /> Property Owner's Mailing Address Property Location <br /> i. 1 -cx::y.ti 4 k -1-c",./.10e 0•- <br /> Govt.Lot <br /> City,State Zip Code Phone Number 1\j W 4 j j i4 y., Section 5 <br /> t\r1GtL:i tSC)11, V,1 l '3.-3713 T _ N' R __ (circle Bone) <br /> U.Type of Building(check all that apply) 411 Lot# <br /> stiA or 2 Family Dwelling-Number of Bedrooms 23 Subdivision Name <br /> Block# bay bre4A1C.. UGt(It's/ <br /> CI Public/Commercial-Describe Use ❑City of ! <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> rkTown of 141 eici k'-fzr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> • <br /> A <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 /> Vff 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) ❑Preheatmerst Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 7C .1- 1r?,-7 <br /> VI.Tank Info Capacity in Total #of I Manufacturer <br /> 'r /11,3!��15 -� <br /> Gallons Gallons Units 1 ci I o <br /> New Tanks Existing Tanks g ¢ ,V M 'g <br /> wU vii r�i, wb5 A. <br /> Septic or Holding Tank iL,cjv it.d�U 1 MEAbE X' <br /> Dosing Chamber <br /> VU.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 /MPRS Number Business Phone Number <br /> kvir e.u.( V\1• i tvthol2 1.--/t-„../ GL . 016.5 (3 <br /> -'76'031 Address(Street,City,State,Zip Code) ( -0.103 <br /> i3 CLAMtiVIV {2t. le- Wai1t1Gt.Re '1 (r.1( • .5-3rii <br /> VIII.Connty/Deparfinent Use Only <br /> Approved ❑Disapproved <br /> Permit Fax Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial S 14 bq.. 10/141/17 /4",iii/4.. •. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> R c ,fl, . , . <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 211 inches in size OCT 17 2011 <br /> r' <br /> Public Health IOC <br /> SBD-6398(R.11/11) Environrrlertibl I I,,,:th <br />