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/1/11 <br /> Cn .Y <br /> ' County rm� _ /E <br /> °, Safety and dlldings;Division — i YY <br /> fr4; 201 W.Washingt•n Ave.,P.O.-BOX 7162 J anitary Permit Number(to be filled in by Co.) <br /> �,~z, P ° ,i Madison, 153707-7162 <br /> S i <br /> 44 r( 3- )14i- pnl 33 <br /> jState Transaction Number <br /> Sanitary Permit Application wzm-Thi3Etts t io,itis <br /> In accordance with SPS 2 383.21 ,Wis.Adm.Code,submission of this form to <br /> ( ) twaiiimFnate go4ijiitehiM�i_m t <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),Stats. ?I 6-°(41)(7Y ® <br /> ��/1 D D p Q n <br /> I. Application Information-Please Print All Information 3t� <br /> Property Owner's Name Parcel# <br /> .1-1,AD 4 ANG-641 FKR Bgietil I D (07(2.- 12.7 _q 96®-a <br /> Property Owner's WIND(i16- <br /> Address Property Location <br /> IND(NC W,A l�/ Govt.Lot <br /> City,State Zip Code Phone Number , , I Z <br /> $� /<, ,sW /a, Section <br /> n (circle one) <br /> K��I �� 53��2 T rT N; R (Z (E9ir W <br /> II.Type of Building(check all that apply) Lot# <br /> *1 or 2 Family Dwelling-Number of Bedrooms ,- Subdivision Name <br /> + 1 employee in shop building Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 15231 -Town of 64. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A New System y CI Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision CIChange 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 /> s-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) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 4515°619.5 001f ?1-69'` 1549 (S-4 1560 f3S.0/ 'etc.() <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units to'0 o <br /> New Tanks Existing Tanks v c = Y a 2 <br /> 350 1550 �t� ,t w O a <br /> Septic oi3 ol4iag Tank I 20s, + 3410 f las Z /rt EAD'G"/ t/ <br /> Dosing Chamber ea) ,®,„ ('r) ( m CAW W ✓ <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'• Sign.• • l /MPRSNumber Business Phone Number <br /> sc.a-rT 6A 401/VW X .. / - 1 3(79, b°e-s'7s- (28q <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2$63 & P— uRcsocrl'TY1 NT ��St3l <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved PermiF� / Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> $ kk <br /> �V 05/24/2021 i <br /> I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 6/)Vxf1 I SK Bel-tit►AAr1N ® I Y Uri- cam <br /> Co, VVr((FM 81ArtWoo/+' ,t nt fl- IP 6 A/4,DP• I F A•PPRoV tt1 ey ,4-1A7foR/c6,r <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> Common owner easement agreement recorded with Register of Deeds office to serve the <br /> mixed commercial use building on the property. Easement agreement attached. <br /> SBD-6398(R. 11/11) <br />