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County` <br /> .�: Industry Services Division ti.+n t <br /> 1400 E Washington Ave <br /> P �' P.O. BOX 62 Sanitary <br /> yPermit Number(to be filled in by Co.) <br /> Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2 1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fomrs 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 / a <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. V vga'F O Ca r Cry <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> (7 rvGz' l3/o�n ��-o/�-a- <br /> /S- d55- d3sam <br /> Property Owner's Mailing Address Property Location <br /> yaS <br /> Govt.Lor <br /> City,Slate Zip Code Phone Number _ ,y W y, Section ,o <br /> 05eOZo/ell l✓1 S9aJ 0 "1- 67/9 T C/o N; R i?ircleonne ) <br /> Ik a <br /> I.Type of Building(checll that apply) Lot# <br /> 1 or 2 Familv Dwelling-Number of Bedrooms as' W �� Subdivision Name <br /> Block# 6fod <br /> ❑Public/Commercial-Describe Use Uta'. <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of .fate KJn n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System � <br /> y El System ❑ Treatment Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit 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 S stem/Com onent/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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> it I . S bad (; 6a 1 WI <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o g <br /> New Tanks Existing Tanks 2 c v c <br /> 0 <br /> Septic or Holding Tank <br /> 7So 7s'o / w I+e s r✓ 1l <br /> Dosing Chamber <br /> VII.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 /> �t i a k frd k 102 s P,:k�e 7,1.f Awi- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 7 G d -Zr i/ebsler✓ 4t/-r- SS`gS7 <br /> VIII.Cour /De artment Use Only <br /> Approved L1 Disapproved Permit Fez Q [D/ate Issued Issuing Agent Signator <br /> ❑ Owner Given Reason for Denial S J 7`6� ' — 4,_O� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �ts7 _ Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 Inches In sin <br /> SBD-6'3998(R0313) <br />