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County j''j <br /> Industry Services Division 914 NN .e <br /> QS .. '1 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> Ps P.O. Box 7162 � nOD <br /> .�"���•yy,i�.-,^�"J Madison,WI 53707-7162 y <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 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(l)(m),Stats. T <br /> L Application Information-Please Print All Information /70P <br /> Property Owner's Name Parcel# <br /> s 0OQNfr o1-e�ta-d�ba-lb-3�_ sdJ -ooN <br /> -s�/em0 <br /> Property Owner's Mailing Address Property Location <br /> Jrt <br /> , -1'7o,OI S—/�B J Gv t-% r 4A--A x Govt.Lot Ye.N <br /> City,State Zip Code Phone Number y,, Section 3/ <br /> S17e�sv Al ✓rSp?y 6,r?z-a757—.i 3S0circle one <br /> It.Type of Building(check all that apply) Lot# c& <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Cotmnercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSIv1 Number ❑ Village of <br /> 3 �, R Town of del 14 dI <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System ❑TreatmenuFlolding 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 /> IV 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(sf) Dispersal Area Proposed(st) System Elevation <br /> 3617 I — I -- <br /> Vt.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units v U$ N <br /> New Tanks Existing Tanks J m <br /> c,V in h rn <br /> Septic or Holding Tank Q�Q d��® ��f Y✓ X <br /> Dosing Chamber <br /> V[[.Responsibility Statement- 1,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 /> /�i -,/e /Y' /,-i$I JS -4-20,4? 7it��G6- c/!,$-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 68 /��At 3.$ Gl/.c6s�Yi jtJr ��8�i <br /> VIII.CounilyflDepartment Use Only <br /> Permit Feer p Date Issued Issuing Agent Sign re <br /> Approved ❑ Disapproved $ 3 7 J t j r <br /> ElOwner Given Reason for Denial J 4 d <br /> ia, <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 8 1/2 x I l inches in size <br /> SBD-6398(80313) <br />