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''.i`% *i`� County � <br /> L '`4 Industry Services Division Cu,r h e 71 <br /> i':. "••': _ 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> r .,�*:y s .'i P.O. Box 7162 C'PIN AD--24D <br /> i,� ::.•;:;: .rf Madison, WI 53707-7162 <br /> z8391 <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 Servies. Personal information you provide may be used for secondary A ct.1£I <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information Co /lei /71 <br /> Property Owner's Name Parcel# -Pi'O y_. • DS <br /> ✓i /1/et N, ��n.[r� L r o7- aa�ol- y <br /> Gh nee dos- Od>Do0 <br /> Property Owner's Mailing Address Property Location 4r/7`S, <br /> 01-5-4 c 3 W ti.Y Y17' L`. Govt.Lot 5-- <br /> City,State Zip Code Phone Number /, %, Section <br /> Ce. L Cc•^0,-i F[. 33911 /J /(circle oone) <br /> II.Type f Building(check all that apply) Lot# T T v N; Rf <br /> i'I or 2 Family Dwelling-Number of Bedrooms Ad Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of fGet 7' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑ New System p Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other ivloditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration r Owner <br /> IV.T"'e of POWTS S stem/Com aonent/Device: (Check all that as.1 <br /> Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 111vlound>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 /> Desi"e i Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 a 0 _ . 7 ydt 5 ei yo 9.1• - ---- <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w e m u 11 y <br /> ainco cr- <br /> . o ti U a <br /> Septic or Holding Tank / bs -e ABs-e, x <br /> i SH f'i/f-Na7,6,- <br /> Dosing Chamber_ i .)t <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/MPRSZ Number Business Phone Number .. <br /> /2/ LIG Nay/ L/✓r S /<�t'4'- —L /1-4,y4.- 04O'J -/ —,',5; Yd - 4-P.c.7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Iss ed Issuing Agent Signatur- <br /> $ 4/❑ Owner Given Reason for Denial 3�.S /a 2d �� n s V��i♦r��-a- <br /> IX.Conditions of Approval/Reasons for Disapprovali ii 11 1 ..n..-p? <br /> OCT 13 2U20 }ji <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2:5 11 inc es to s 'matt County <br /> w :.tx9 Services Departme <br /> aci <br /> SBD-6398(R0313) 44 rtur....._- 01.1 -`t - (o <br />