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Industry Services Division County <br /> 9 1400 E Washington Ave vrnt �' <br /> P.O.Box 7162 Sanitary Permit Numl�pr(to be filled inuy�Cg.) <br /> S Madison,WI 53707 7162 NA�2 2 7,0 <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 permiL 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(I)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Add ess <br /> Property Location <br /> Z;! d. Govt.Lot <br /> City,State Zip Code Phone Number yj %,, Section <br /> 6 // 5y�y�v (circle one) <br /> II.Type of Building(c eck all that apply) Lot?r T N; R EorW <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ❑Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System WReplacement 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 /> IV.TVPe of POWTS S stem/Com onent/Device: (Check all that apply <br /> W Non-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holdins Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaU Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> yZq 1 42 140 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = <br /> New Tanks Existing Tanks a = v v H y <br /> E c E <br /> a U in ti iL V a <br /> Septic or Holding Tank B ^+ I t <br /> Dosing Chamber co I (� 57 <br /> s'V <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> 1Plu cr's Name(Print) Plumber's Sig �+ MP/MPRS Number Business Phone Number <br /> �114 � �5lg5z� s�-o�z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 8t �y L k �/ �Jeis c„1t• 5�g9 <br /> VIII.Court /De artment Use Only <br /> ❑Approved ❑Disapproved Permit Fee� Date Issued i g 'Sign <br /> ❑Owner Given Reason for Denial 5 �'I ! f� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CK-41.2213 `� 7 <br /> L <br /> FQ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t(?s 11 loci in NOV <br /> Ra[ <br /> $umett County <br /> SSD 6398(R.08114) Lanai Services DeaA, <br />