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County <br /> r<�= <br /> Industry Services Division K r✓t-d <br /> '2£1 1400 E Washington Ave - - _ - - <br /> � . .. . <br /> 9 Sanitary Permit Number(to be tilled 7- Co.) <br /> P.O. Box 7162 �'R� I <br /> Madison, WI 53707-7162 g <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 goverunental 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 maybe used for secondary yr( <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),S tats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# H <br /> 07-a3&- -�e-i7-3�-5/.� - �d <br /> Ca ph Wto -Tom Ma-4Zo - oti3008 <br /> Property Owner's Mailing Address Property Location # 6W <br /> . 6Y 81 k e 34OriC '. Govt.Lot <br /> City,State Zip Code Phone Number y, V4, Section 3 K' <br /> E A /" N f s/d� (circle o <br /> II.Tyjl. of Building(check all that apply) Lot it T_ 40 N; R 1:7 E o <br /> 1 or Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Conunercial-Describe Use <br /> ❑ City of ' <br /> ❑State Owned—Describe Use CSNI Number Village of <br /> YTown of (n V1 1 60% <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..f ...e,of POWiCS..S stem/Com onent/I)evice: (Check all that apply) <br /> Non P es 1-Yz d In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑fVgld.Ing:Tarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> WDs e>sal/Treatment Area Information: <br /> Design Flo+ri(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 d6? _ — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � P o A <br /> New Tanks Existing Tanks � o u � V <br /> c U In in ci U a <br /> Septic or Holding Tank Al <br /> Dosing Chamber- Se�O O S.yv Th�/ /�✓���� t r It <br /> VH.Responsibility.Statement-I,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 /> Zr e-IC /AP k IV's <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit�F]ee Date[Issqued'n Issuinggn Agent Snignature <br /> El Given Reason for Denial I 101 <br /> l ( LV L�����!/� — <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> re <br /> Tow o),k c(71.t�'t ( S-kt-�e u i re.�i�,ufs _ 0 C T 17 2023 <br /> c , <br /> � tx,Q,S -fo V2✓s r u, 2. ► � .��� � <br /> e C� UA+ V1�1a�� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 s I inches In si28urnett County <br /> Land Services Department <br /> QQn Lino rnn„i� <br />