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S(t •'i;t,I/r. Cl'l.tt tic.It-.21. County ii,,Z..) lik:s Safety and Buildings Division !>>�'�t.,i i 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) Madison,WI 53707-7162kms__ _ /3--2e 2-/ 067/1; -, � Sanitary Pei mit 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 Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. I. Application Information-Please Print All.Information �_ 3 EYe t 11i:-'.`>(7-�. ti O, Property Owner's Name Parcel 4 J CFF 12-t E-ir.e.:w 1- c'7(::ii)— it.- j l 7-6, Property Owner's Mailing Address Property Location ,S'>‘.._•J iti'I C-.t ec,, -to. Govt Lot City,State Zip Code Phone Number I." ' > i 'A, Section 12.. i:'-'5 ,�. (circle one) li�,A Q t�<:_..+\! a•..11 - -7 ic` _ T to N• R t O E or-W II.Type of Building(check all that apply) Lot 4 El or 2 Family Dwelling-Number ofBcdrooms t---7-2I Subdivision Name Block ❑Public/Commercial-Describe Use ❑City of • CSM Number 0 Village of ❑State Owned-Describe Use _ El"Torun of DO i`.i N 227 III.Type of Permit: (Cheer only one box on tine A. Complete line B if applicable) •fl° Le w•System y"�Replacement System ❑Treatment/Holding Tank Replacement Daly ❑Other Modification to Existing System(explain) B. 0 Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner N-gg'1-1- 6,A ,l'FAA he -L:- IV.Type of POWTS System/Component/Device: (Check nil that apply) kft St TATA 7---01, 7.<1.,,i) i re"m ,I f/A aO;/ 1.)41- w�.,t Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gude ❑Monad 24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.DispersulfTreatment Area Information: Design Flow(gpd) Design Soil Application Rnte(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation , e ') -) ,.j I.'-',t 55 ir'.'./1) 4-11-i.=6,`t3.1'i q--5..c3, VI.Tank Info Capacity Ca act in Total • 4 of Manufacturer Gallons Units ° Gallons U New Tanks Existing Tanks o , w„ Q id a a. U in rn ii: 0 F... Septic or Bolding Tank i lac fT) --- 1 t` 0 i ltd 1.1 Dosing Chamber ] r VII.Responsibillity Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature .r - P/MPRS Number Business Phone Number Plumber's Address(Street,City,State,Zip(Code) L:=":2'1"3 C 1'(- 42---;:).. '_ I1\Jt ti;tLiie.e..<" ; ii. k 5f51ir'7 VIII.County/Department Use Only 1--- nr/G PA I L&.�, GG ( -2q ZD?I �r Permit Fee t3.--14 � 'pate Issued Issuing Agent Signature ("� ml Approved ❑Disapproved S F,- v� �j l fJ ❑Owner Given Reason for Denial r ° f (;- 2 t-J l- -1'i`i'y t,t( L�'''�J:(•x- t 4----,_,, -IX.Conditions of Approval/Reasons for Disapproval Existing Tank(s) and Drainfield to be properly abandoned prior to or as part of . replacement system installation, including pumping& reporting to PHMDC. - Attach to complete puns for the system and calunit r„the County only on paper not less than 11 la 5 11 inches in size Ensure tank locations are within 150' to all-weather service pad and within 15'vertical depth sBD-6 difference to all-weather service pad-Specific servicing mechanics must be provided if exceeded.'