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Industry Services Division county <br /> D yi, 1400 E Washington Ave �N <br /> PA Box 7162 <br /> Madison,WI 53707-7162 and Petamt Number(to be fined in by Co.) <br /> r�er�o�r 6sT-23 —R o l'b� <br /> Sanitary Permit Application StateThnsactionNumbe <br /> In accordance with SPS 383.21(2).Nis.Adm.Code,submission of this form to the appropriate goveramauai unit <br /> is required prior to obtaining a sanitary permit Note Application forms for suiteowned POWTS ate submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal i 0mmation you provide tray be used for secondary <br /> oses in accordaace with the Privacy Law,s,15.04 1 m Smts. ' J <br /> I. A lication Information—Please Print All Information Z 55a7 /V. U! <br /> Property Owner's Name Parcel.# <br /> avyN �ovdoueAj <br /> Property Owner's Mailing Address Property Location <br /> '`l flovt Lot <br /> City,State / Zip code Phone Number y,, y, Section Z 6 <br /> T 22 N. R /61 or <br /> w a) <br /> U.Type of Building(cheek all that apply) Lot# <br /> 1 or 2 Family-Dtvelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Dmibe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of _ <br /> V t 08 <br /> 3 Town of �dV6AJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if appUcable) <br /> A, 13 New System ❑Replacement <br /> ys ep System ❑Treauaent/Holding Ttark Repiacematt Only ❑Other Modification to ExistingSystem(explain) <br /> B• ❑Permit Renewal ❑Pamit Re%ision ❑Change ofPhtmber 13 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Tnx of POWTS System/Component/Device. Check all.that apply) <br /> C Non-Pressurized Indlround ❑hasuriaed la4round ❑At-Giude ❑Mound!24 in.ofsuitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Devine(erplain) <br /> V.Dispersal/Treatment Area Information: <br /> Design O(gpd) Design Sail Application Rate(gpdsf) Dispersal Area Required(sf) 1 Area Proposed sf) system 7 D 7 ( 7iy14T15 <br /> VI.Tank Info Capaaty in Total #of Mamriacttmer <br /> Gallons Gallons Units <br /> New Tanks m ist'urg Tanks <br /> U y a a3 ii� a <br /> Septic or Holding Task 2670 <br /> Dmg Chamber 5-0 <br /> V11.Res onsiblilly Statement-L the underai@aed,assume lity for Lrstai>atioa of the POWTS shown on the attached plans. <br /> P u cr's Name(/P/rint)1 Plumbds 5 _ MP/I11PRS Number Busi>�S Phone Number <br /> Piumbsr's City,Suite,Zip Code) <br /> l(�?,V,;/7w <br /> 1.e ;4/ <br /> VIII.Coup epartinent Use Only <br /> Approved ❑Disapproved Pe/rnmh see Datelmwd <br /> A 'r <br /> a Owner Given Reason far Denial S <br /> 7.4 67 /--N rr= n�\ /7 rF3 <br /> IX.Conditions of ApprovallReaso for D G a�( for <br /> rnw5� 3�+ o� se -h��'I� Aluo 1 <br /> alb Igo net Ca,�l e.�r>?,� <br /> AttaeiY m plus slrsle�ssttuhmit m the oaq as paper am lean tlua tt ui z I twin tasks u <br /> Land Services Department <br /> 25V C�IAI(, 12(v I Z <br /> SBD-6398(R,08114) <br />