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Cc 1 <br /> Industry Services Division t_er e 7T <br /> ita <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 p <br /> Madison, WI 53707-7162 <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 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 (o t.(,}"g <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Narne CPa r el <br /> Property Owner's Mailing Address ,4 Property Location 3 <br /> 3� 69 f Owi1 View uc NF Govt.Lot <br /> City,State Zip Code Phone Number y , <br /> r /o, Section <br /> S-j- A✓►1'11 o✓l,>t m N ircle one) <br /> yb l� <br /> I1.Type of Building(check all that apply) Lot# c <br /> T N; R �� E or <br /> I or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ Ciry of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> OTownof 66kCJ4s d- <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System DRe lacement System <br /> y p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑ Change of PIumber FOwner <br /> mit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV.1yipe.of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> ZK P e razed In-Ground 11Pressurized In-Ground ❑ At-Grade El Mound>24 in.of suitable soil 11 Mound<24 in.of suitable soil <br /> ❑KdldiriTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V JDISM.s.'al/Treatment Area Information: <br /> Desigrr_H6(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> L,►„S'0 . 7 1 &1Y3 loSo 9N.11 43.H 9J..,1i <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units •o d, U � y •� <br /> New Tanks Existing Tanks o <br /> a.U �n- ti rn ii C7 G. <br /> Septic or Holding Tank <br /> Dosing Chamber_ 5710 6 <br /> 40 <br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu e IvIP/MPRS Number Business Phone Number <br /> /fir c le rL�a lc,n.r l<%u.�.-,,��/ },f�Y.S1 7iS-�166- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I � <br /> VIIL Coun /De artment Use Only <br /> )<Approved ❑ Disapproved Pen-nit Feev Date Issued Issuing Age Signature _ <br /> ❑ Owner Given Reason for Denial <br /> IX Conditions of Approval/Reasons f Disapproval [En/] <br /> loee- a u S G D v <br /> JUL 2 0 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 in es in si e <br /> umett County <br /> Land Services DepeRment <br /> SBD-6398(R0313) <br />