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Industry Services Division County <br /> 1400 E Washington Ave V(r/(, <br /> I-1 $p i.; P.O.Box 716.2 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 <br /> \ . 63-:007 <br /> •ti3i•. <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),Stats. Z M„_l <br /> I. Application Information—Please Print All Information w fir <br /> Property Owner's Name Parcel# <br /> Nev/ <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> 7 <br /> City,State 7 Zip Code Phone Number ya, ''/i, Section 27 <br /> 50 t ) J0 arcleon <br /> T ( _N; R Eot <br /> II.Type of Building(check all that apply) Lot# <br /> 1KI or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town of UNION <br /> Ili.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 ❑ ❑Permit Transfer to New of Plumber Change List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/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 /> RHolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> t6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks w = L y y <br /> a` U rn ; in iiz <br /> Septic or Holding Tank � O <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> PI er's Name(Print) Plumber's Sig MP/MPRS Number Business Phone Number <br /> T 11Q � /G90� ��!9 5z/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> l0eef I Avohw I/k WO/ (f\/4-9/e, <br /> VI 1.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued issuing Agent Signature <br /> ❑Owner Given Reason for Denial I <br /> $ 37 7 �� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 15. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tr2 s t in sin <br /> APR 15 2021 <br /> SBD-6398(R.08/14) umett County <br /> Land Services Department <br />