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2£a�reatar�rok Co'�`� <br /> Safety and Buildings Division v�N <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> 4 Madison,WI 53707-7162 <br /> Sanitary Permit Application State TransactionNnmber <br /> In accordance with SPS 38321(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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(lXmX Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Name // Parcel# o 7 o3 3 7 <br /> Property Owner's Mailing Adcffiss Property Location <br /> �? 7 L 1e<1 d Govt Lot <br /> City,State Zip Cade Phone Number y� y,, Section 7� <br /> (circle o <br /> rr^e-del/c GJ S y937 T_37 N, R1 EorW <br /> II.Type of Building(cheek all that apply) Lot# <br /> ❑ Subdivision Name <br /> 1 or 2 Family Dwelling—Number of Bedrooms <br /> L Block# <br /> X-Public/Com icacial—Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use C�Q K oL <br /> �Townof <br /> Ib Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑Treatmem(Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision CO)Change Of Plumber ❑Permit Transfer to New List Vous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Typeof POWTS S em/Com onenUDevice: Check all that apply) <br /> l/J1Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Ci ade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Preueatmeut Device(explam) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info C��m Gallons 'Units manufacturer U o v <br /> Q <br /> m U V7 <br /> New Tacks Existing Talks w U rn m yr w c7 Q+ <br /> Septic or HotdiapZank f SG' Ipso ' <br /> > s Chamber 75G <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature Mp/MPRc Number Business Phone Number <br /> 7414 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved 11O <br /> Disapproved _ Q <br /> ❑Owner G7S-, <br /> 7iven Reason for Denial $ 3/ 3 , l Q-1/(/ <br /> M Conditions of ApprovaUReasons for Disapproval D <br /> OCT 19 2016 <br /> Attach to complete pl o for the system and submit to the County only oa paper not►ess than 8 tra x 11' IPIN ETT CO IA ITY <br /> ZONING T <br />