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Industry Services Division County <br /> 0 1400 E Washington Ave �— <br /> "s{ ,\5' P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <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 Pro) t Add e s(if diffe nt than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary &ID f 'AC_ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name / Parcel# D 7 <br /> 40 <br /> )4 NC IYO^J - ,2d9-17-,,7 - 0J-CW-011&V <br /> Property Owner's Mailing Address / Property Location <br /> 777 7 A�he! Govt.Lot <br /> City,State Zip Code Phone Number , , Z <br /> f y �/ /�,—�/� Section—� <br /> rcle on <br /> T N; R. E or1W <br /> II.Type of Building(check all that apply) 77 Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms !i Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of - <br /> Town of <br /> III.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 ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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 /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design <br /> 7Fllo'w'I(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersall Area Proposed(sf) Sys tem EElevation <br /> 760 VIA", <br /> 06 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v ^ <br /> New Tanks Existing Tanks w u m <br /> a`U in y rn tL C7 a <br /> Septic or Holding Tank �( <br /> Dosing Chamber 2 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) / Plumbe' gnaturc MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � fI Avoba I k ;&e7r/ kJe6c2Ar U, 5y09 <br /> VIII,Coun /De artment Use Only <br /> I \Npproved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial 1 3 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not Ices than 8 a�} <br /> SBD-6398(R.08/14) <br /> cttxrettt.unt} <br /> Department -�f <br />