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County <br /> r}' < Industry Services Division <br /> a. <br /> Q 1400 E Washington Ave <br /> Sanitary Permit Number to be tilled in b Co.) <br /> P,S `� P.O. Box 7162 <br /> ` Number( <br /> y <br /> � ,/ Madison, WI 53707-7162 <br /> 3-5 <br /> Sanitary Permit Application State Iransaction 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 Servies. Personal information you provide may be used for secondary 7 a 3 v <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �� �� a ��� <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> L> o7-0JR�46 i618ioy oao <br /> Property Owner's Mailing Address Property Location <br /> PQ Z?a k 31S-- Govt.Lot------��� <br /> City,State Zip Code Phone Number E y,AT y,� Section <br /> t'il/ f /�St�"✓ 1� �$—y��i3 ��� L— 3/`1c7 (circle one <br /> clo <br /> II.Type of Building(check all that apply) y Lot# T `TO N; R /& _G <br /> 1'I or 2 Family Dwelling-Number of Bedrooms a Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ,.❑,{Village of <br /> Kfl Town of C f le-/6 h 0/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System <br /> ❑ Treatment/Holding"lank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑ Permit Revision ❑Change 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 /> 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(gpdst) Dispersal Arca Required(st) Dispersal Area Proposed(st) System Elevation <br /> v�-e G �/3 �� g 9a• 9 u 9/. 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks •� d <br /> septic or Holding Tank /m r OF /040 <br /> /.y /-0,C C✓ 7� <br /> Dosing Chamber <br /> VQ.Responsibility Statement- 1,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 /> /2t c/c /✓d /� , r s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � INS6 rKe. <br /> V11f.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee V0 <br /> )Date Issued 1— Issuing Agent Signa re <br /> ElOwner Given Reason for Denial $ 3 /S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> op ECEovE FF <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 11 inc u s in a OCT U <br /> 2015 <br /> SBD-6398(R0313) 13URNETT COUNTY <br /> ZONING <br />