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-T`, Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 anit Permit Nu ber(to be filV ri by Co.)_2 <br /> S Madison,WI53707 7162 5 ..��� 'v�/ (v—tQ to(,f <br /> t, T <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fort to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forts 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. <br /> I. Application Information-Please Print All information \ 7 <br /> Property Owner's Name Parcel# <br /> J eMWeAm5ooi <br /> Property Owner's Mailing Address Property Location <br /> 4��/4 �� Govt.Lot <br /> City,State ZiipiCCo�d ? Phone Number y,, %,, Section_3 <br /> Z <br /> ✓ •(J91/ T N, R (gircleone <br /> II.Type of Building(check all that apply) r� Lot# — _ <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms y /v Subdivision Name <br /> ❑ l``�Public/Commercial-Describe Use Block# e, <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of _ <br /> Q Torn of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ❑Replacement System IrTreatment/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 /> S ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> N Non-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 Fa ,fired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3G� 7 3 � d <br /> VI.Tank Info Capacity in Total TM of Manufacturer <br /> Gallons Gallons Units <br /> g <br /> New Tanks Esistin¢Tanks _ <br /> a U <br /> Septic or Holding Tani: Apt, <br /> Chamber D(/ N <br /> VIL Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> P is Name(Print) Plu is natures MP/MPRS Number Business Phone Number <br /> 61 J ' X'9 57'Z/- <br /> luZPlumber's Add--0 6ress(Street,City,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> ❑Approved ❑Disapproved Permit Fee �v Date Issued Issuin ge Signa <br /> ❑ S 2 <br /> Owner Given Reason for Denial <br /> al <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CC� LE0V IE <br /> Attach to complete plans for the s-'stem and submit to the County only on paper not less than 8 if,x I l i ze <br /> OCT - 7 20N <br /> SBD-6398(R 08114) <br /> umett ounty <br /> Land ServiceS Department <br />