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Industry Services Division County <br /> 1400 E Washington Ave f�e <br /> S' P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI53707-7162 5n,.1 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this farm to the appropriate governmental unit �p 5,�;l <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to P Address(if different than mailing address) <br /> roject <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary Ir 8 7 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. 2 �g'� <br /> I. A "Application Information—Please Print All Information / 6vof <br /> Property Owner's Name Jaw Parcel# <br /> N p��G4r� Z- 0-W —`a' o5�A7Z- Azb <br /> Property Owner's Mailing Address Property Location <br /> ZZ /vvl'G Trz Govt.Lot-7— <br /> City,State Zip Code Phone Number Y4, %, Section Z <br /> f IVA[ rle one) <br /> T 4/1P N; R /�✓ E or W <br /> II.Type of Building(check all that apply) Lot# <br /> 49 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> UA t Town of . q <br /> 111.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A* ❑New System <br /> y Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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.DispersalfTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> . y5b 1 — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D c v <br /> New Tanks Existing Tanks Z. <br /> ` o y a cs <br /> a V in H in 'u. C7 a <br /> Scptic or Holding Tank Z600 Z,00 <br /> Dosing Chamber (J 7� <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P crP 's Name(Print) Plumber's arc MP/MPRS Number Business Phone Number <br /> lu <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G Lf %Vel/r4 l k �/ kle�b5 c,✓,• 5yg9 <br /> VIII.County/ e artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> \\ ❑Owner Given Reason for Denial $ 37- L/ Zy Z� J <br /> IX.Conditions of Approval/Reasons for Disapproval G✓ <br /> /Y1,r.ihf I'e <br /> Attach to complete plans for the system and submit to the County only on paper not less;than S to x I I Inches in size <br /> SBD-6398(R.08/14) <br />