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oFxAarMcvr Industry Services Division County 4822 Madison Yards Way <br /> -' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> 3 # K P.O.Box 7302 _ w <br /> Madison,WI 5302 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. 4496 Deerpath Trl <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> John&Barbara Bechtel <br /> 07-012-2-40-15-10-5 15-128-118100 <br /> Property Owner's Mailing Address Property Location <br /> PO Box 208 <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Webster,WI 54893 '/,, /<, Section 10 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 E or W <br /> I 1 or 2 Family Dwelling—Number of Bedrooms I Subdivision Name <br /> Deerpath Add to Voyager Village <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> #5357 VOL30 P264 ❑Town of Jackson <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑Holding Tank ❑In-Ground ❑ At-Grade ❑Mound ❑Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to New Owner <br /> st Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> fa ��/ CJ <br /> Capacity in Total #of Manufacturer 0 IL <br /> Tank Information Gallons Gallons Units A 10 U $ y N <br /> New Tanks Existing Tanks q ;? 15 y a <br /> Septic or HaidiSf=nk <br /> Dosing Chamber (/ <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name( ' t),,' / Plumber,s Signature r MP/MPRS/Number Business Phone Number/ <br /> A1� �c`/�a7 s �i �z74 7 [ 3�9 7� '6 <br /> Plumb Zs Address(Street,City State,Zip bode) <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date issued Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial $ <br /> Conditions of,.,Approval/Reasons <br /> !'for Disapproval <br /> 43 <br /> D <br /> i APR 14 2C, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x inches in si*Lffnett County <br /> Land Services Department <br /> SBD-6398(R 02/22) <br />