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County <br /> ` Industry Services Division 3(� Y✓t 1P <br /> - <br /> �r 1400 E Washington Ave SaniEa Permit Number(to be tilled in by Co.) <br /> Sanitary rmit <br /> �.�._ <br /> P.O. Bax 7162 _ <br /> Madison,WI 53707-7162 � .r <br /> afy i y•-7�' / <br /> Sanitary Permit Application State Transaction Number <br /> [n accordance with SPS 383.21(2),Wis.Adm.Code,subtrtission of this form to the appropriate governmental unit <br /> is,required prior to obtaining a sanitary permit. Note:Applicatioa forms for state-owned PO4VCS are submitted to Project Address(if different than mailing address) <br /> the Departtnent of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> purposes in of <br /> with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name oleo ,},"_/r <br /> G dohFU OI sad 0 <br /> Property Owner's Mailing Address Property Location <br /> 13Gnn+e.✓' LlG l�� Govt.Lot <br /> City,State Zip Cade Phone Number /, '/<, Section 3 <br /> ��h�N� ` S2rl�3V cle one <br /> 11.Type of Building(check all that apply) Lot# T 4 N; R / (cir E or <br /> �l or2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of ' <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> �Townof ,>aGKSoki <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 ElPermit Revision ❑Change of Plumber I El Permit Transfer to New IList Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..T y`p*e.of POW iTS..S stem/Com onent/Uevice: (Check all that apply) <br /> `N—L e uriyed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Efq[atnP Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V D:s`'ersaI/Treatment Area Information: t. <br /> Design~ oW(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units New Tanks Existing Tanks 2 o[VI. <br /> eptic or Holding Tank /&G y, <br /> Dosing Chamber- i 3 <br /> VII.responsibility Statement-I,the undersigned,assume responsibility for installation of the POWPS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa_Wree NIP/MPRS Number Business Phone Number <br /> 21c,IG �rf c,N _ <br /> Plumber's Address(Street,City,State,Zip Code) 57 <br /> VIII. our !De artment Use Only <br /> Approved ❑ Disapproved Permit Pee 'Dilate[ss e�d�J[/ Issuing Agent Signature <br /> ❑Owner Given Reason for Denial �� � " & ! <br /> IX Conditions of Approval/Reasons for Disapproval t� <br /> meth Q.0 Rf�,,'as D [E <br /> �llOr,� CEME <br /> U'D (W/7f7 rA 3'7U`�r i� .1 J N 1 1 Z02.4. <br /> Attach to complete plans for the system and submit to the County oaly on paper not less than 8 1/2 s I l ches i �UrnOtt County <br /> Land Services Department <br />