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<br /> keART Industry Services Division County "
<br /> Ley 1
<br /> . AU","::: 4822Ivladison Yards Way Dane
<br /> �a ;;..T. Madison,WI 53705 Sanitary PermitMunber
<br /> Lary (to be filled in by Co.)
<br /> _:<e P.O:Box 7162
<br /> .,,ti Madison,WI53707--7162 13-2021-00212� Sanitary Permit Application State Transaction Number
<br /> In accordance with SPS 383.21(21 Wis,Mm.Code,submission of this form to the appropriate.governmental unit '
<br /> •
<br /> is required prior to obtaining a sanitary pemrit.Note:Application forms for state-owned.POWTS are submitted to Project Address(if different than Mailing'address) i
<br /> the Department of Safety and Professional Services:Personal information you provide may beused for secondary
<br /> purposes in accordance with the Privacy Law,s.15 04(1)(m) Stats.
<br /> J 'A O1111MDrr :`.'fir:F y:."3'•'.: ...s,<'s':; ° ,=''t fi'k '
<br /> Property Owner'sNaine 2 7217 Tri County Road ;
<br /> Sharon M Hein Parcel# 0912-134-8001-0
<br /> nnan dOA. aA7n n
<br /> Property Owner's Mailing Address j
<br /> Property Location
<br /> 7215 Tri County Road Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> Waterloo, WI 53594 NE %, SE %, section 13 {
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<br /> O 1 or 2 Family Dwelling—Number ofEledrooms .4 Subdivision Name
<br /> ❑Public/Commercial_Describe Use
<br /> Ck
<br /> C City of
<br /> O State Owned—Describe Use
<br /> CSM Number
<br /> C7 Village of
<br /> 15724 1D.Townof York
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<br /> ❑.New System �Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain)
<br /> B.
<br /> ❑Holding Tank El In-Ground ❑At -Grade ❑Mound ❑Individual Site Design. O Other Type(explain):
<br /> (conventional)
<br /> C. ❑Renewal Before ❑Revision ❑Change of Plumber ❑Transfer to New Owner List Previous Pemrit Number and Date Issued j
<br /> Expiration
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<br /> Design Flow(god) Design Soil Application d/ Dispersal :Dispersal
<br /> Area Propos. z(s:)..:: yste.<> El: w Elevation ;t .n:.>>,rt:;`.a_ j
<br /> gP � p Area Required(s��, 'Dispersal Area Proposed(s fl System Elevation
<br /> e!a�3L7 1$6094,
<br /> a ;
<br /> 1 S k ct 9x:'-1 1
<br /> Capacity in Total #of Manufacturer
<br /> TankInformation Gallons
<br /> Gallons Units �u
<br /> New Tanks Existing Tanksti. U ,. �,
<br /> 4d , A to r.
<br /> Septic orHolding Tank f ?—O C; __ (Zr:2•0 --- i
<br /> Basing Chamber
<br /> i
<br /> c: ulrsYaRitaCYWa^ RWfgafi�trAWAPIN �4
<br /> Es 4 f
<br /> PIumber's Name(Print) Plum i's Signatue MP/MVMPRS Number Bushiest Phone Number
<br /> Steven J Tesmer a.— ,.cLis.. ZZ"?f i(.
<br /> 608-837-5297 •
<br /> Plumber's Address(Street City,State,Zip Code) j
<br /> N8458 County Road 0 Waterloo, WI 53594
<br /> 1.:C} ittin$ Entp* yit H m Sta1 SMssEw . xr: 6rvERIytzlif ;• arthEit * uL €
<br /> Approved El Disapproved Permit Fee Pate Issued Issuing Agent Signature
<br /> 0QtvnerGiven Reason for Denial $ 464.00 07/16/2021 i
<br /> Conditions of Approval/Reasons for Disapproval
<br /> 1
<br /> Existing septic tank to be properly abandoned per code requirements.
<br /> I
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 81t2 x11 inches in size
<br /> SBD-6398(R.03/21)
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