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, <br /> -'''i.,, Industry Services Division County <br /> /.2=-7 <br /> ( <br /> 4822 Madison Yards Way DAhlE <br /> ' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> 1:P=/..:,/ <br /> .! P.O.Box 7162 <br /> •-..'/.;,,, ,,..4.-- Madison,WI 53707-7162 13-2021-00234 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information b l X C C) t2-IDL-E TPA-it-- <br /> Property <br /> iL_Property Owner's Name Parcel# <br /> VC t•t4 '1 i-11 L1,`> LL_C. <-77a- i o i - 2F1f-1--U <br /> Property Owner's Mailing Address Property Location <br /> L'l.- Vv (-i L.-t\22-i•Z-V sT. Govt.Lot <br /> City,State ` Zip Code Phone Number <br /> 1.0 G_1-�-{= ie C. 11---) , VAS i 5,7))53( NW 1/4, NE 1, Section 1° <br /> IL Type of Building(check all that apply) Lot# T 7 N R it E or-W/ <br /> Ell or 2 Family Dwelling-Number of Bedrooms `T 1 Subdivision Name <br /> Block# i'r✓t•.►N.E0.1 iLL <br /> ElPublic/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> 1/`Town of CL &f•-"E <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A' ONew <br /> System Deplacement System ather Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> ) <br /> B. ❑Holding Tank Iffn-Ground <br /> ❑4t-Grade Mound ❑Individual Site Design ]Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision Change of Plumber ❑transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpd/sf) Dispersal Area Required(of) Dispersal Arca Proposed(sf) System Elevation <br /> t.-C,C. 0,i-1- i5na 150023.05 22.c-.../ <br /> Capacity in Total #of Manufacturer <br /> te Tank Information Gallons Gallons Units c' b• U y <br /> New Tanks Existing Tanks o a°'i a 41 <br /> a U ii, a cn w CD a. <br /> _ <br /> Septic or Holding Tank 1 Z¢.. — 124.:-k-- j MF I= I <br /> Dosing Chamber CX: �c 2 1 IVvE,xy( 2C I ❑ ❑I❑ <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> AVArcw (A.I• MeivIti (Q___ _---4,_,--e-- L,___, -------(f c�i t�53i-s3l<x3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> t.-i c`Tv(. (24) K Vv/tellv ,1/4&.E_ I ;J i 5"3 h 41-1 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Si rr� <br /> 14 <br /> ❑Owner Given Reason for Denial S 464.00 08/03/2021 �l` I <br /> Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 X 11 inches in size <br /> SBD-6398(R.03/21) <br />