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ryt x� FC )'-� Industry Services Division, ..,mod 1400 E Washington Ave umber(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> ,x; Madison, WI 53707-7162 <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 PO4VTS 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 77 y1Q►YAf/1 R <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> ft din^d_ S-/S <br /> 4iq7717 0130ob <br /> Property Owner's Mailing Address Property Location <br /> ?0 43 C v -7 3 Govt.Lot <br /> City,State Zip Code Phone Number y, y, Section <br /> ��� b u✓y (circle one <br /> II.Type of Building(check all that apply) Lot# T N; R (b E or( <br /> El I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ®Town of O 0�- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 5(New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑Pennit Revision ❑Change of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Ty pe of POWTS.S stem/Com onent/Device: (Check all that appl ) <br /> 71�rbu=P,essi ized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ IioldingTaak ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VtDisLrsal/Treatment Area Information: <br /> DesfgnT16*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Re uired(sf) Dispersal Area Proposed(st) System Elevation <br /> JS-p . '7 iSg ) lk e <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o <br /> 0 rn v, cn u U Gi <br /> Septic or Holding Tank 3),0 Y f er <br /> Dosing Chamber_ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbe s Name(Print) Plumber's Signature 1vlP/MPRS Number Business Phone Number <br /> Plu er's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Pennit Fee Date Issued Issuing Agent Si azure <br /> ❑ Owner Given Reason for Denial $ -37,r/ Zf Z/ <br /> IX.Conditions of Approval/Reasons for Disapproval C11 A wD-75 I <br /> qCECDC0VE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 if ize t <br /> urnett County <br /> SBD-6398(R0313) Land Services Department <br />