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County <br /> ,y% F ritif^.✓I1 <br /> Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> �. <br /> � P.O.Box 7162 -a,l_57 <br /> Madison,WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govermnental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary k s-7 O <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Co RA jQ <br /> I. Application Information-Please Print All Information Parcel# y0_ /y,�/_d o�•o00 <br /> Property Owner's Name o7-c.�8�d' b 101 ode <br /> Property Location <br /> Property Owner's Mailing Address <br /> a 9137d�0 /-/i / �(-d....e 17d- Govt.Lot <br /> City,State Zip Code Phone Number y, '/4, Section a <br /> at (circle one) <br /> T �� N; P /y E orO <br /> II.Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑ m rtile-Public/Comercial-Describe Use A , ' <br /> by i�L1 3+b%bef El city of <br /> CSM Number p Village of <br /> ❑State Owned-Describe Use Town of f�O <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ® New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pennit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.f e of POVJTS.S stem/Com onent/Device: (Check all that apply) <br /> Non Pies razed In-Ground El Pressurized In-Ground ❑ At-Grade ElMound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ElPretreatment Device(explain) <br /> ❑ FlgldmaTank ElOther Dispersal Component(explain) <br /> V Dis ers'al/Treatment Area Information: Dispersal Area Proposed st System Elevation <br /> Design-Ed*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) P P ( ) <br /> VI.Tank Info Capacity in Total #of Manufacturer Y <br /> p U <br /> Gallons Gallons Units V y N <br /> NzwTanks Existing Tanks "_' ij Y <br /> c.U v� ti rn w V Cti <br /> Septic or Holding Tank 3L O 3d O <br /> Dosing Chamber- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> Plumber's Address(SIreet,City,State,Zip Code) <br /> 771�0 ,t <br /> VIII.County/De artment Use Only <br /> Permit Fee Date[ssued Issuing Agent Signature _. <br /> �pproved El Disapproved <br /> El Owner Given Reason for Denial $ -7.3 I �� � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D <br /> Attach to complete plans For the system and submit to the County only on paper not less than 8 I 11 hes t <br /> urnett County <br /> 4RD-6398 rRn3131 Land Services Department <br />