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County <br /> Industry Services Division t3K rn le <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 716202� —a7 <br /> Madison, WI 53707-7162 <br /> � f <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 govermnental unit <br /> is required prior to obtaining a sanitary permit. Note;Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary /Q <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information 2 6 L 5 <br /> Property Owner's Name Parcel# <br /> f l o e- iS-S3S- O/Sago <br /> Property Owner's Mailing Address Property Location <br /> 3oI 4V'P /t/W Govt.Lot 1�87 <br /> City,State Zip Code Phone Number y, y,, Section b <br /> v1 JQV e N SS 3 4 (circle one) <br /> Y' <br /> II.Type of Building(check all that apply) ? Lot# T y N; R�E or� <br /> I or 2 Family Dwelling—Number of Bedrooms J Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use P,I- (�/k <br /> ❑ City of <br /> CSM Number Village of <br /> Q State Owned—Describe Use }� l <br /> to✓a 30 Town of C> fG �d•�O' <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System ,V Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Pen-nit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..T e of POW'I'S.S stem/Com onent/Device: (Check all that apply) <br /> ❑�ioa I'r iinzed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil Q Mound<24 in.ofsuitable soil <br /> ❑,HoldtrtyTatik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dis` ess'aI/Treatment Area Information: <br /> Derr-OfFIirtr(gpd) Design Soil.Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> gs-tq — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a tJ <br /> New Tanks Existing Tanks o �? 15 t <br /> CZ u U a <br /> Septic or Holding Tank 3 0 0 d )06� IN t Sr r57 <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 IYIP/MPRS Number Business;Phone Number <br /> 00 <br /> Plumber's Address(Stye t,City,State,Zip Code) /—C i \ <br /> 7 G o w �� �i✓-�kr t� J / <br /> VIII.Coun ep artment Use Onl <br /> A';kpproved El Disapproved <br /> Permit Fee Date Issued Issuing Age t Sign e <br /> ❑ Owner Given Reason for Denial $ Z1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> DOE <br /> C l D rsF� - 2 s z N1 A <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in. in s in size <br /> umett County <br /> SBD-6393(R0313) <br /> Land Services Department <br />