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Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �y Madison,WI 53707-7162 � <br /> �urnro..... 35� <br /> lk 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 /> es u os m accordance with the PrivacyLaw,s.15.04 1 (m),Stats. L <br /> L A lication Information-Please Print All Information Z ,� PT ,CA-A-4 e £ <br /> Property Owner's Name <br /> 11 Parcel#O .a <br /> Or <br /> Property Owner's Mailing Address Property Location <br /> IAJ <br /> Govt.Lot <br /> City,State Zip Code Phone Number �� <br /> /., Section O <br /> ircle one <br /> H.Type of Building(elleck all that apply)- Lot# <br /> ❑1 or2 Family Dwelling-Number ofBedrooms t+p Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of l/ <br /> Town of r/el Q-lam Z <br /> M.Type of P rmit: (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 ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> VE]No <br /> Type of POWTS System/Component/Device: Check all that apply) <br /> ressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> g Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/T reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 00 — .�- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o L, <br /> New Tanks Existing Tanks m 5 U <br /> wU <br /> Sep or Holding �j <br /> Dosing Chamber OOfJ / `�` l/✓ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS.- on the attached plans. <br /> P m er's Name(Print) Plumber's Signature Number Business Phone Number <br /> a C k > awl ;ti ZLZQ72, ?ltS <br /> Pinter's A dress(Street,City,State,Zip Co S de) <br /> P,t C, K'A L 1L C,� <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ 7-f <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z nc in size <br /> MAY 13 2021 <br /> SBD-6398(R.08/14) Bumett County <br /> land Services Department <br /> Boa t-3-7-1>, <br />