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N <br /> �,,3 .. 0.,, County <br /> 7 / ''r= Indust,,— -1 •'� Industry Services Division i3u✓yr 1� <br /> n A'1 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ` P.O. Box 7162 Stw <br /> r� <br /> 4:. '�. 1,r� Madison, WI 53707-7162 3 �1J��3 <br /> State Transaction Number <br /> Sanitary Peiinit 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 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# ti 0—16-18_ 'r-S pei <br /> Property Owner's Mailing Address Property Location <br /> 14'3l(a, <br /> ), ? 75-9 L; 'redo", r?r vet.- god <br /> Govt.Lot <br /> City,State Zip Comic Phone Number / 'A,, Section 3 <br /> au;b.►....,. 1,0— J Zi i/5'3 0 T yDN; R /cmc(eEeo4 one <br /> II.Type of Building(check all that apply) Lot# <br /> i?I or 2 Family Dwelling—Number of Bedrooms 6, Subdivision Name , <br /> Block# <br /> • <br /> 0 Public/Cotnmercial-Describe Use ❑ City of • <br /> ❑State Owned—Describe Use CSIv[Number ❑ Village of <br /> TO Town of O4,c w 444.04` <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ,Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ElChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.{'ype of POWTSSystem/Component/Device: (Check all that apply) <br /> oir n fms urized In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑EfolamgTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> WIN§reUal/Treatment Area Information: ,. <br /> DeS I-0'M*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer p ,L, <br /> Septic or Holding Tank . . . <br /> Dosing Chamber_ ___ -- ! .)' IIII <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 Signature / MP/MPRS Number Business Phone Number <br /> RIG lc 14 k,h -, /2,-<. /.4, 2/1- . 05J 6'.S) Z/.. I-. G- //457 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> __ 77,e ?--- 25--- V $ -. i 5 Y5` . <br /> VI I.Coun /Department Use Only <br /> Approved ❑Disapproved Permit Fezor) Date Issued s :Age t S''.aturz <br /> ❑Owner Given Reason for Denial �✓ 01111193 .li . ; (�. ,_ • - - _ <br /> IX.Conditions of ApprR sons oval/ for Disapproval II C V L ' V <br /> M ct 11 5c �; t , c, f u'At 5o386 <br /> JUN 14 2023 <br /> i. if,5� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/3 x I I inches in-ize C urnett County <br /> Land Services Department <br />