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y. ;,'.. r� ;.\ County <br /> _ .;. `+„,, IndustryServices Division 1.3tkee e <br /> r y: t`.t ;i.; ;, -` 1400 E Washington Ave <br /> rA <br /> ,r ,�`,.�..,., ,., 9 Sanitary Permit Number(to be tilled in b Co <br /> pi <br /> P.O. Box 7162 (mil o6?3 <br /> ' ; ';'�...! `., Madison, WI 53707-7162 5 ft NI ^ 03(`335 <br /> State Transaction Number <br /> Sanitary Permit 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 an <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information J�e��✓Savt Trµ / <br /> Property Owner's Name Parcel# _ <br /> /Zl-L-fG. /a-e4t,cSdv� o7-0�gd-yG-/`t-/3-S6o/lao0 357$5 <br /> Property Owner's Mailing Address Property Location <br /> /)45 /"Wier S0v► Tr's; i Govt.Lot 3 <br /> City,State Zip Code Phone Number <br /> /<, Section 13 <br /> sppG d s7 e r <br /> - �b/ (circle one <br /> II.Type of Building(check allthat apply) Lot# T izio N; R /y E or <br /> I or 2 Family Dwelling-Number of Bedrooms J. 3 Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 0 Town of 'e a79 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' lit New System 0 Replacement System <br /> yp y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. El 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 POWTSSystem/Component/Device: (Check all that apply) <br /> ❑NThi Pre urized In-Ground ❑ Pressurized In-Ground ❑ At Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> I'Ioldtn�Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V,Dispersal/Treatment Area Information: ,, <br /> DesFgnFlory(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ..?. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units - o '� <br /> U �' N <br /> New Tanks Existing Tanks 9 ' g . 01 <br /> 0 <br /> c U 'cn ti cn w o a <br /> Septic or Holding Tank 1Gtee al 000 / 44.//t f r// V <br /> Dosing Chamber.. ! - <br /> VII.Responsibility Statement-. I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /Z/e/c /4/6,Am f /2 •-"-(// ),I.-es'/ '7/.7- 8G6—yi5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> i <br /> 7 7`a //r~.}, 3,S / J e-6 s7.,-.- wr s s'1.? C-7- <br /> VIII.Court /De'artment Use Onl <br /> Permit Fee Date Issued Issu..: A -nt Si• 'i��!iI <br /> r Approved 0 Disapproved r m' <br /> 0 Owner Given Reason for Denial 375 1 'f 1a' :`t , <br /> IX.Conditions of Approval/Reasons for Disapproval % , '" <br /> 75w N "z <br /> F. <br /> :Z .')i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ua s It inches in size `1 K ill' ^./ <br /> SBD-6398 (R0313) <br />