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County <br /> Safety and Buildings Division taAtJE <br /> 201 W. Washington Ave., P.O. BOR 7162 San Lary Permit Number(to be filled iriby Co.) <br /> Its _ Madison, WI 53707-7162 <br /> • <br /> �� 13-2021 -00128 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis. Mm. 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 Scrvies. Personal information you provide may be used for seconday <br /> purposes in accordance with the Privacy Law. s. 15.040Xm), Stats. �j. 7 <br /> L Application information -Please Print All Information Parcel k <br /> Property Owner's Name <br /> Eric RT. <>Iz..NEy 4c — s do Greg & Chelsie Ebert o1fa- 3-f I - 1615-0 <br /> Property Location <br /> property Owner's Mailing Address <br /> szg2. eil-i .--n Govt-Lot <br /> City,State Zip Code ?bone Number SE 1/2,14E-. Ye Section 34 <br /> • <br /> MhAt t r v-.1 i 5355ry (circle onc)l N: R � <br /> - <br /> I7Type of Building(check a! tbat apply) Lot a <br /> ,-� i Subdivision Name <br /> m l or 2 Family Dwelling-Number of Bedrooms, <br /> Block <br /> ❑Public/Commercial-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> El State Owned-Describe Use Town of t11O2K. <br /> 151.:S.2- <br /> DI Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. /New System 0 Replacement System 0 TreatmentHolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> i List Previous Permit Number and Date issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner _ i <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized lnGround ❑ Pressurized In-Ground E rAt.Grade ❑ Mound>24 in.of suitable soil 0 Mouml<24 is of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device (cxplain)_ <br /> V.Dlspersalfrreatment Area Rate(gpdsQDispersalInformation:Application AreaArm Required(sf) Dispersal AProposed (s0 System Elevation <br /> o, i.e Ieco IiclaD ell. 5' <br /> VI. Tank Info _ Capitally in Total I/ of Manufacturer <br /> e <br /> Gallons _ Gallons Unita sj E y <br /> New Tank f Taal 77.�va�..,' a. J N u N w V et. <br /> Sefucor Holding Talk I2 rt;'-� <br /> — . I 1Yi x <br /> painChamber (090 <br /> f,.� I MEACX rc. <br /> VU. Responsibility Statement- L the undersigned,assume responsibility for Installation of the FOWLS shown on the attached plans. <br /> Phone Number <br /> Plumber's Signature S&•lWRS Number <br /> Members Name (Print) <br /> AYl KIy vtii kt!il1I\C(.= 1 l <br /> ...✓C, s-��."-- 2-24` 11--, 6013' 3 t'131(113 <br /> Plumber's Address(Street,City, State,Zip Code) <br /> Las sly. PO. le 1..3 .t,,_r1LtL're , Rai 5% -7 <br /> VOL Conn !Department Use Only Date Issued I Issuing Agee[Sineturca.'� <br /> Permit FeeJJ//(l/r//JJ// <br /> X Approved ❑ Disapproved 51360.00 05/28/2021Issued ; <br /> ❑ Owner Given Reason for Denial - ._— -- - <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> Protect At-Grade site and area 15 feet downslope in its natural condition. <br /> No compaction, disturbance, excavation or vehicular traffic is allowed. <br /> — Attach CO compkte plass for the system sed sobmtt to the County only oa paper cot las taloa in a I I laches in size <br /> SBD-6398 (R. 11/1 I) <br />