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_ County �! Safety and Buildings Division Q1t�tE i 201 W.Washington Ave.,P.O.Box 7162 Sanitary Pettish Number(to be filled in by Cu.) wL) :r Madison,WI 53707-7162 QJµbvLt-1 ' Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 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) the Department of Safety and Professional Servics. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ,-1- t F,6}�/.76L Application Information-Please Print All InformationnPatel 1 Property Owner's Name At,iNII VE1ZSAt'.y LA7EAm ESr-A rE5 LLC 07c(..-ti 1-soz)i-S Property Owner's Mailing Address Property Location 791' 'AIZ1—Cto.1 aV. Govt Lot City,State I Zip Code Phone Number N E 'A,1.1E '/,Section 1 i (circle enc) CPOSS R./NI KIS 1 v,\l X3`320 T 7 N; R l e e) IL Type of Building(check aft that apply) Lot s Subdivision Name gl or 2 Family Dwelling-Number of Bedrooms Block 4 3z+.I PSE P,2Cf1 ❑Public/Commercial-Describe Use 0 City of CSM Number 0 Village of ❑State Owned-Describe Use 17'Townof VEaMONT III Type of Permit: (Check,one box on line A. Complete line B if applicable) A. E-New Syatam ❑Replacement Syne ' ❑T t/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) 0Permit transfer to New List Previous Permit Number and Date Issued B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ^ / Before Expiration Owner •5 AN -1366 '7 C ri i il/YZ h t W.Type of POWTS System/Component/Device: (Check all that apply) O Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24in.ofsuitable soil !IMound<24 in.of tuitable soil ❑Holding Tank 0 Other Dispersal Component(explain) - 0 Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Rete(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation AA SO 6.s4c c-- //.a((Ll pi.„a1750) 'ACV GO( (12,-,gtic) #9,.ci Li q i.33 t VI.Tank Info Capacity in Total I II of Manufacturerfi Gallons Gallons Units o o- New Teaks Existing Talcs e.U .ro el', y,13 p. Sepik or Holding Tank 1 tom` — 11 CO 1 MEPSC . X Dosing Chamber I.-CCs _ bCt) I MEAX s. VD-Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plena. Plumber's Name(Print) Plumber's Signature MP/MS Number Business Phone Number rn il'olott ,.i t%I. t`•' . hc4L .1PR _/t•-r�— f,J a°t i,.5 e3 t•X3(03 Plumber's Address(Street,City,State,Zip Code) ((�/ tceA C .(2-0, t- Wau.naka i li,i 53`ell x. C.0 `� - , �t VIII. rConnt�/DCI Disapproved asa ant Use Only 5y A, 1( � Permit Fee Dote Issued /� Issuing Agent Signature ((C/ Approved ❑Owner Give $ 1 j� ' 7 ,� t�l�� 0 Owner Given Reason for Denial 1 S� !U 2Q IX.Conditions of Approval/Reasons for Disapproval i Existing home torn down March 2021,vacant prior to that since Dec 2020. Existing Sanitary system SAN-1355 to be properly abandoned per code,including pumping and reporting to -PHMDC. Protect mound site and 15 feet downslope in its natural condition. NO compaction, excavation, or vehicular traffic allowed. Ensure tank locations are within 150'to all-weather service pad and within 15'vertical depth difference to all- weather service pad.Specific servicing mechanics must be provided if exceeded.