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Industry Services Division County <br /> `, 1400 E Washington Ave <br /> /'t , ® �' P.O.Box 7162 <br /> �zl �.\as Sanit ryPermit Numbe (to be filled in by Co.) <br /> ,7, s Madison,WI 53701-7162 sA _).i -1 v5 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 8�`Z <br /> /11 k 9 ,D ;7 of <br /> Property Owner's Mailing Address ,, • <br /> Property Location <br /> 21 /�w g,• Govt.Lot <br /> City,State lip Code Phone Number y,, %,, Section l� <br /> N& f� -410, D ircle on <br /> w 15' E orV <br /> II.Type of Building(check all that apply) Lot# T 'YO N; R <br /> VT I or 2 Family Dwelling-Number of Bedrooms Z 57 Subdivision Name ,, <br /> Block# �(^,� � V_V <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of L_ _ ' <br /> Town of ]Re I <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 19 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 S stem/Com onent/Device: Check all that apply) <br /> DrNon-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3x) 1 . 7 112,17 1 `/72 1 9y3- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 9 o v <br /> New Tanks Existing Tanks y y a o <br /> a U in H cn is. C7 t% <br /> Septic or Holding Tank <br /> Dosing Chamber Jury\ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print) Plumber' ature MP/MPRS Number17/5--10-620-Z <br /> Business Phone Number <br /> T�1Q 4/ ,lam �5�9 5 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8/ A A w [A Wel kAehcA V,- 5-'7009 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $37.5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nn LSCEO V E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 4ibevi size <br /> MAN 2 5 2021 <br /> SBD-6398(R.08/14) umett County <br /> Land Services Department <br />