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Industry Services Division County 1 <br /> 7- <br /> - 0 •;._•, 1400 E Washington Ave - <br /> �T% <br /> {zl S� P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t. S Madison,WI 53707 7162 ,�p,�-z 2 -!I (0y 3 t.{o q <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 Services.Personal information you provide may be used for secondary 1$ga <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information �^J <br /> Property Owner's Name Parcel T <br /> '4AJILO, wl 7 0L -V1* -f <br /> Property Owner's Mailing AAdress <br /> Property Location <br /> 7G Govt.Lot � t <br /> City,State Zip Code Phone Number y., V,, Section 3 <br /> A.-f W 5��8 rcleon <br /> T�N; R E0& <br /> II.Type of IBuilding(check all that apply) Lot <br /> 1 or 2 Family Dwelling-Numbcr of Bedrooms Subdivision Name <br /> Block t <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of L <br /> IR To.of �L07�T <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/Holding 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 /> X Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ADO 5 5"I 172.e> <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units ' o a <br /> New Tanks Existin_Tanks U o <br /> p a' R u L tys <br /> �.U in y y ti ij a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P?05e7 <br /> er's Name(Print) -/ Plumber's Sign MP/MPRS Number Business Phonc Number <br /> Q w 7 T ll /w�i �5«5z/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G 81 Avoh w t A W/ (le6t ltr V, 709 <br /> VIII.County/ e artment Use Only <br /> Approved ❑Disapproved Permit Fee t:X� Date Issued uin Age Signature <br /> ❑Owner Given Reason for Denial S LI rl�'I /(� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Sep R- evis FEB 4 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less tha 8 to S ne -mW OU y <br /> Land Services Department <br /> SBD-6398(R.08/14) <br /> q�5°° <br />