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,�•-- Coutay ", Safety and Buildings Division -r iE 'N 201 W.Washington Ave.,P.O.Box 7162 �Sanitary Permit Number(to be filled in by Co.) :at W Madison,WI 53707-7162 s.-(it, •submitted online 04/16/2021 i 13-2021-00072 Sanitary Permit Application 1 State Transaction Number In accordance with SPS 383.21(2).W is.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 arc submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may he used for secondary purposes in accolitnce with the Pnvacy Law,s.15.04(1)(m),Stats. ....... L Application Information--Please Print All Information C _iN• ' Property Owner's Name Parcel S 1 AM VCE` i-k1 - ,p..1-?, L.1,- r2)3'•-•••'-',-c7 Property Owner's Mailing Address ` t�lProperty Location 211 t'l -ij-'A'{1 1'<> "'“2.4%.1.t_ 1 Govt.Lot City,State rp Code Phone Number — I i�E y; jly sl.,Section }(" (circle one Ivt i l]L ti'l t`t i h'n „r _>`.>t._l. T_ N;N; R y F trrW II Type of Building(check all that app Lot I) �,I Subdivision Name ®1 or 2 Family Dwelling-Number of Be ms / Blaek» I ❑Public/Commercial-Describe Use_ -_ U City of - CSM Number I 0 Village of ❑State Owned-Describe Ilse1— -._--- c)N sA[)}'Townof V C-P ITL Type of Permit: (Check only one bon en line A. Complete line B if applicable) 1 A. fJ New System CI Replacement System 0 Treatment/Holding rack Replacement Only 0 Other Modificationm,Existing System(explain) 0i 0 Change of Plumber ❑Permit'transfer to New ! last Previous Permit Number and Date Issued B. 0 Permit Renewal Permit Revisori Before Expiration Owner I IV.Type of POWTS System/Component/Device: (Check all that apply) ❑Non-Pressurised In-Ground 0 Pressurized lo-Ground 0 At-Grade Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil ❑Holding Tank 0 Other Dislnsal Component(explain) -_ 0 Pretreatment Device(explain)— _ V.Dispersal/Treatment Arca Information: Design Flow( Design Sw 1' scion Rate/Fist) Dispc t Required(A) i Dispersal Att/a Protriel(st) I System Elevation g gPdi 6 t,Q` i�-/. I tot `�1Cn.� fGII4v 1 1 •K� (in '11I.i<.' (.'c e • i ' l VI.Tank Info j Capacity in I Total #of Manufactu„r ' o c y ^ Gallons Gallons Units a . U ,-, New Tank: Existing Tanks I S a 11 la.U v ."!-4.n ti 0 C. Sntic or Holding Tank )`7,X -.-- 1'2Si.- 1 y Pei E-P<t:,t- it Dosing Chamber t.,t..-- ' t-` 1 _..+ Mekti3�, j •� I ( I t VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POW9'S shown on the attached plans. Plumber's Name(Print) Plumber's Signature X>Rls.'MPRS Number Business Phone Number ,._ o.: htr}' z-i.;_. ,�..- i.,......) .9 c�3t,s�jt07 ir` PittaTber's Address(Scree[,City,Stau:,Lip Cate) 6,..„„•:. t Ti. (1.) (�. t,J I U-..•.,'.i <P, b�i __ _ ...__. - VIII.County/Department Use Only pd cc onlinA 0411RI • permit Fee i Date lssutxt Issuing Agent Signature XApproved Disapproved s 1360 4/20/ 021 Owner Given Reason for Denial 1 `; '!'- - hg(xti„,.‘ , ... jz.'I 0 IX.Conditions of Approval/Reasons for Disapproval ENSURE PROPER TANR(S)ALL-WEATHER SERVICE_ACCESSIBILITY: V[JSLIGALPOTA IJAA.Ntlls)ADTIOM se StallikE PAD:<IS Fr Protect 8t Maintain:t Mound/❑At-Grade site and 15 feet downslope in its natural - NORmoMAL DISTANCE TANxts)TO SERVICE PAD:<I50 FT condition. No compaction,excavation,disturbance,or vehicular traffic allowed. c.i.f.- "naakrnonta must neproemee irvertical s>utr/bort:onto,>150 ft Attach to complete plans for the system and submit to the County only on paper not Is than II t2 a 11 Inches in sire /Any-iycLs --IP ke ca-i' di t /i 41 atit " 1.,yam S64//,12?Cup`76,47 itake SBD-6398(R.11/11)