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County <br /> Industry Services Division /3c�rh <br /> r : D 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co,) <br /> P P.O. Box 7162 �// <br /> Madison, WI 53707-7162 3�``/`-r <br /> S+xscti'`j ��i —Q <br /> on N <br /> Sanitary Permit Application State Transactiumber <br /> In accordance with SPS 383.21(2),W is.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 PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information l 4' t✓{'' /7� <br /> Property Owner's Name Parcel# <br /> �(G/L /Sart U7. p3.Z—d • f <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot I `� <br /> City,State Zip Code Phone Number ,I 3 <br /> /., (�%� Section <br /> sf• l�Nrti/<✓ 11 A/ (circle one) <br /> ,❑1..Type of Building(check all that apply) Lot# T N; <br /> Er 1 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 /> V .0 <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X New System y ❑ Replacement System ❑Treannent/I Wiling 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,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 Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> �!�D -*= a S Sao I Sao 93 o x 7,a <br /> Vi.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o v <br /> New Tanks Existing Tanks •v v Y � �'� <br /> Septic or Holding Tank <br /> Dosing Chamber w Gia <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pnnq Plumber's Signature MP/MPRS Number Business Phone Number <br /> f/a 4 le I H * � ZY JhAs-8f"/ 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7? G a z-el—X 3J- <br /> V111. <br /> s Lv e 6s�•. > 3 <br /> ,,V}111.Count /De artment Use Only <br /> IpJ Approved ❑ Disapproved Permit Fee Date Issued Issu' A en[S' alur <br /> CA <br /> f� ❑ Owner Given Reason for Denial $ 37 5'' <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 less than S 12 s It inches in size <br /> SBD-6398(R0313) <br />