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„�-' ;; Industry Services Division County <br /> ry: <br /> 1;x, ® ,c% 1400 E Washington Ave <br /> utN <br /> 1=1 .. Sp • P.O.Box 7162 <br /> Sanitary Permit Number(to be filled in by Co-) <br /> 10145 iiii-'7 <br /> \, :,', :.--.es:,`;a: Madison,WI 53707-7162 5N _ �_ <br /> 5Sanitary 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. <br /> I. Application Information-Please Print All Information 670 Ohl 3C <br /> Property Owner's Name Parcel# <br /> kay oNtoi b 07=a32e4Y/45--/6/a y-Sao-ai/aoo <br /> Property Owner's Mailing Address <br /> Property Location <br /> 5876 old cc Govt.Lot <br /> City,State Zip Code Phone Number t” t <br /> O4N�IY7 ` �4 1/4, R %,, Section <br /> Ur( Sctrcleone <br /> H.Type of Builds g(check all that apply) Lot# T �� N; R ,� E' a,� <br /> 43 1 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of it l/V <br /> Hl.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> °Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Areaequired(at) Dispersal Area Proposed(sf) System E <br /> lnR:6/ . 1 Y 2 1:5-- <br /> VI. <br /> � <br /> VI. <br /> Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ^ <br /> New Tanks Existing Tanks c v .E <br /> _ V - N <br /> a U in y y i.` 6 a. <br /> Septic or Holding Tank boo W <br /> Boo / 5 .! X <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> s. <br /> ?tun ex's Name(Print)// I Plumber's '_n re MP/MPRS Number Business Phone Number <br /> �/Q �/ 1 /G`�f 86/952-1 J -1 7/'" ✓id-02o <br /> mh r s Address(Street,City,State,Zip Code) +- i <br /> S8/ /7'IJ77`a nl lie A' �e,6 W 5 ' 9 <br /> VIII.County/Department Use Only <br /> Permit Fee Op Date Issued Iss ung A nt Signa <br /> Int Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial S LOS u` a'� • <br /> IX.Conditions of Ap p r o v a casops for Disapproval <br /> OiMee-f- ail —Fr-1E© Ej V <br /> J <br /> AIS [ 5 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tn_S 1b m size ' <br /> —Ern e t t County <br /> Land Services Department <br /> SBD-6398(R.08114) <br />