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ara*� l County <br /> Industry Services Division h<—IV- <br /> ,�3 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ri Q <br /> 5 ¢ P.O. Box 7162 Ji�— 185 <br /> y� Madison,WI 53707-7162 <br /> ,1v <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 ;283J12 <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 Servies. 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 /eA.WE m ih 5 IV <br /> Property Owner's Name Parcel# <br /> Le�c w t77 <br /> V/ ewt 4 /d oD� /3/0 <br /> Property Owner's Mailing Address Property Location tT 74XI <br /> L_�" 134 h Ac St /" E Govt.Lot <br /> City,State Zip Code Phone Number /, y,, Section .! <br /> M / AW f �� (circle one <br /> II.Type of(Building(check all that apply) Lot# T�v N; R �6 E o <br /> t or 2 Family Dwelling—Number of Bedrooms �� Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number 0 Village of <br /> Town of Ox_/.caa4 <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑New System Replacement System p y g y (explain) <br /> ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System <br /> B• ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration IOwner <br /> IV.Typeof POWTS.S stem/Com onent/Device: (Check all that apply) <br /> Non Press razed In-Ground ❑ Pressurized to-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Haldm�Tank ❑Other bis etsal Component(explain) <br /> ) ❑Pretreatment Device(explain) <br /> V <br /> iDpersaI/Treatment Area Information: <br /> DesguFlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> es v . 7 8Gel, 5'00 5 • y <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o o <br /> a <br /> New Tanks Existing Tanks <br /> 0 <br /> c.U v, rn <br /> Septic or Holding Tank AU-0 s�G/}1✓ X <br /> Dosing Chamber.. <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POIYWS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 4 le-/C /ye e/c,�+s l2�•G r� d J,.s`8.s�� _7/.f-,6W- y1,s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> —7 w <br /> VILL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit�e Date sued ssutng gent Si,gna e <br /> $ <br /> ❑ 35 0� ZGo <br /> Owner Given Reason for Denial _ <br /> IX.Conditions of Approval/Reashatons for Disapprove' <br /> eI pit <br /> -*�?Swshw, w Wkeft oA I&Imm� sfi�c ►et+ <br /> WAS at& wsk will be re gty�e� JwArt eswsfrkcjl�9 'Ks, 6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 he i size <br /> urnett aunty <br /> SBD-6393(R0313) Land Services Department <br />