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--e.g`a''J',•N. County <br /> ..?., • '''1:r+ Industry Services Division e3t4r h t- <br /> ; t I t` ,: .: ., 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> z i 51 P.O. Box 7162 - 2 2 - 1 ba <br /> �. :`fir Madison, WI 53707-7162 �`�,�j 3 <br /> l ;- CT-S- 22- 123 <br /> State Transaction Number <br /> Sanitary Pet mit Application <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 Servies. Personal information you provide may be used for secondary 4-1 3 Oa _ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �1L /I i, / cr , <br /> I. Application Information-Please Print All Information )' ' <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> 6SCA ) Daw i /q"e N Govt.Lot <br /> City,State Zip Code Phone Number % Ye, Section <br /> eleZ <br /> G ly A rs ,"St3 i trcle one) <br /> �h l�N rb t/e ` T to N; R 1 E orNV/ <br /> II.Type of Building(check all that apply) Lot# <br /> I or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block y <br /> • <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 1d Town of U 4 J o•n <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> A. ''KNew System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision <br /> ❑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 /> *itNaTi=twWiTiled In-Ground ❑ Pressurized In-Ground ❑ At:Grade El Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ IfoldmgTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V'Dispersal/Treatment Area Information: <br /> Des i Flb*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 670 7 Y5-o dad 93. o <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units -rn o ' o <br /> New Tanks Existing Tanks 8 ,Cl v 0 v 1i ro d <br /> aU m . CO wLI w <br /> Septic or Holding Tank 750 co / Lt// f e' X <br /> Dosing Chamber_ / ,a <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signs <br /> SSigns re /� IvIP/MPRS Number Business Phone Number <br /> R/(.k- Ji/o kI DI / ."_"."."[ T'4 GA ASgS/ "7/.�= g i— L1/--`7 <br /> Plumber's Address(Stree,City,State,Zip Code) <br /> 7/—L O /`744..y 3s Zv-e dshor w_____j3 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Penult Fee Date Issued Issuing nt Si,, <br /> ❑ Owner Given Reason for Denial $ ((f 5� 7/►51 a? J ' <br /> IX.Conditior;s of AGip�'val/3Zear isapproval U V <br /> 7- 7l8�2 <br /> 7 JUL 12 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/?s 11 r,'hes size.'{.(/ <br /> umett County <br /> SBD-6393 (R0313) Land Services Department <br />