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Not. installe <br /> --- <br /> `': •a;.,; Industry Services Division County <br /> < 1400 E Washington Ave U(L <br /> ' III "`' P.O.Box 7162 <br /> r Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> _ 1 L 1 ) <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 pnor to obtaining a sanitary permit.Note:Application forms for state-owned POWTS arc 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 /> , u_r uses in accordance with the Privacy Law,s. 15.040 Xm),Stats 3 5 I o 11.5 1 k' O 1) <br /> I. Application Information-Please Print All Information <br /> Prcinty Owner's N ne Parcel 8 <br /> /d (f,tv e., J 0'{G C o n o Location 3 35736 0 i <br /> Property Owner's,`ailiing Address 1 Property /4/60 45 <br /> , , i J W E 5 L t L ",/ Govt.Lot <br /> City,State Zip Code �r Phone Number y,, 'A, Section 7 <br /> � re"-) I t&cl T S �N 5-S �( p tide on <br /> '�J � � T � 0 N; R �� E orIg) <br /> II.Type of Building(check all that apply) Lot tt <br /> ig I or 2 Family Dwelling-Number of Bedit sris___ Subdivision Name <br /> Block 8 <br /> ❑PuhlroCommercial-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use V ( 5_ P a a 6 0 Town of OA k L.4/4 1) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A jSew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration I Owner <br /> IV.Type of POWTS St•stem(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) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(st) System Elevation <br /> 3 00 <br /> VI.Tank Info Capacity in Total 8 of Manufacturer <br /> Gallons Gallons Units U$ ad <br /> c I <br /> Y1 1Nrw Tanks I:usras I ink s <br /> a in D a.t7 a. <br /> ��Septic a tioklmg Tank .1 C O ' <br /> Dosing Chamber -7 5-0 - - <br /> VII.Responsibility.Statement- I.the undersigned,assume est ty for installation of the POW "tto non the attached plans. <br /> Plum ' Name(Print) Plumber's Sig - ure PRS Number Business Phone Number <br /> Plumber's Address(Street,Cm,State,Zip Code) <br /> p 1,1 ( �7- Y iju 1 9,20A, F✓t— I cl '1.71 <br /> VIII.County/Department Use Only Issuing Agent gnature <br /> Permit Fee Date Issued Approval 0 Diatsppmved s-- 7,s, 12,^ / -Z/ Z <br /> 0 Owner Given Reason for Denial <br /> IX,Conditions of Approval/Reasons for Disapproval <br /> 4 Z A c)i /ram ALA- <br /> Attach to complete plans far the system and submit to the County only on Met not teas than 8 1/2 1 11 inebea in size <br />