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01/ii16 5--Z8-24)2/
<br /> �l-- County
<br /> i Safely and 81}Idings Dlv! n 1 1�i, t
<br /> 2t7 4 W.Washington Ave.,P.O.Box 7162 Seni ary Perm t Number(ta be fitted inby Co.)'a hit Madison,WI 537()7-.7162
<br /> l 13-104-- U/
<br /> Sanitary Permit Application State TrmsactionNumber
<br /> Iaaccni iance with SPS 31d3 21(2),Wis.Adm.Code,e.fc. tisalon of this fuiut to the appropriate gmertunenral unit
<br /> Fs tegeired ptiorto obtaining a sanitary permit Note:Applicata..iattns I state-owned POWTS are suhat[ttcd to Pra=t Adehc:,(if different than mailing address)
<br /> the Depatttacat of Safety and Prefcssiemd Sawa m Personal intorno:ion you ptmVide et3y be Wad"or ceccnd44Ty Drw�Nfi,d.1 Po c ei f
<br /> pm-pow laser-mance wick the Privacy LLW,t.15.b4(l)(m),Stati, _ 0108 gat,—
<br /> I.Appbcation ittfon ntion-Please Print AB Information i N`F;4'}-t-1( 4117-'...'i7-1-- 2 t SS-4i
<br /> Pro petty Owner's blame Parcel ti
<br /> r l4 5e-, 4--72".4.,
<br /> airy. TTIi'i u., c:t<- = xc MAP _7, sae t i.-t'- ('_5 Y-iG, - 074.e,-3O - V74r
<br /> Pieperty Owner's Mailing Address Property Location
<br /> E- G-7 t L e_;(2-4 tvt L l2. C.twt ILAT
<br /> City,State Zip Codi. Phone Number hi V i 5a,•`4A..,' ri,Statins �--)
<br /> Yi 1(( ! �— (aleck sac)
<br /> IUi✓ttl-*LS A,`+. 0_11 `~'" T 7 ti,- R 5 --Eo,-W
<br /> If.Type of Building(slack that that apply) Let
<br /> Subdivision 1Namo
<br /> Qlor2Family DwtlPmrip-Neemlerafll droams
<br /> Iite:ckF �9�
<br /> 0 Publia'Commetcial-Dracrbe Use_ 0 City of
<br /> CSM i ntnbex 0 Villar of __--
<br /> 0 State Owned-Describe Use_ t a-i
<br /> f'Town of illi( 4.
<br /> M.Type of Permit: (Cheek only one box an line A. Complete line B if applicable)
<br /> A J0
<br /> ®New System 0 Replacement System 0 Tleak?ZnUHoldinETaak Replacement Only Other Mofieization to arising System(explain)
<br /> ' List Ptet10u3 Pdtmft Nhimber and Data Tsatui
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber OPermit Tuns,fersoNoW
<br /> Before Expiration Owner -
<br /> .TV.Type_of POWTS SystemlComponentillevice: (Check all that apply) ---�
<br /> 0 Woo-Pres sunned tn.Ornund 0 PressnrUed In-Ground 0 Al-Grade Missend?34 in.of suitable soil 0 Mound<24 is of suitable soil
<br /> 0Holding Tank 0Other Dispersal Component{erplainj 0Pretreatment Device(explain} -, - �..�.
<br /> V.DlspersatfI'rtetmentArea Information: System Design Flow(gad) Design sail Application Rate(gpdsp ' Dispersal Ares Required(afi Dispersal Ana Proposed(sf}
<br /> Total r o£ Manuf`oI c;
<br /> Vl.Tani info Capacity in 4 t
<br /> Gallons Gallons Units i . E ;.d I .t
<br /> N w Tads Lei sin r,n is rt c, Its L ! u, -d, 5' F.
<br /> T �t i'l.'1t... 1 fvlci'1.Y_.: v^ .�
<br /> Septic orFIaLttag srY I ,'_2. I ,
<br /> e
<br /> Dosing t a:nhes ,.t_ f..%'-.7 1 tv;r:1y �.
<br /> s-?
<br /> VII.RtaponAAbllity Statement-I.the undersigned,assume responsibility far installation erne POWTS atom on the attached plans.
<br /> Plumber's Nath(Print) olbcr s Signature /. •AfW'.W7IPRS Number Business Phan Number
<br /> Plember'e Address(Street,City,State,Zip Code)
<br /> (...,-A,.2,(-.771s-f. 1.:1 '-t - Ietrt1.14-i]A t lr:ty..53C70
<br /> VIII.County/Department use Dalyt'„,=—S--7-61---40 Z! ...f- -
<br /> Permit Fee issued Agent Siattue r/
<br /> Approcct4 �O D(sapProva9 S /3(00 19 i(7uLed' 14 411 Cft f As. /G-
<br /> 0 ft Gay=Rcawa for Menial -
<br /> IX.Conditions of Approval/Reasons for Disapproval eaLsc rin0.,4. c ttot- S.fLt_,,,A. /%,o•Fe ot G5 AA-h'-cc.p
<br /> Protect& Maintain:X Mound/0 At-Grade site and 15 feet downslope in its natural
<br /> condition. No compaction, excavation, disturbance, or vehicular traffic allowed. I
<br /> --- ._ . ...t.m...aar not loci than 6 la n 1I both.to sizs
<br /> Ensure tank locations are within 150'to all-weather service pad and within 15'vertical depth
<br /> difference to all-weatherservicepad-Specific servicing'mechanics must be provided/ if�ex�c�eeded?�\
<br /> 5130-6 ire .'i i t s it Jt'..4-T 13(0'0✓✓4/x,9/` 74),—✓VLQ.)� E, cin_ (.I', -r-\JI-•a_k.
<br /> 'f1t.(-( (K r et"P�-*i a�—'J a Li rte d t D S.i• ec ia-,cr turd vI. c fir-i Y-Lou
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