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ON 9OMPUTER/SCANNED <br /> County n <br /> Industry Services Division !s a r n-e'er <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> S p `� P.O. Box 7162 <br /> 000 0 1 15—J,�0 <br /> Madison,WI 53707-7162 <br /> 4��,�. <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 govenunental 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 trailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. na A3 M-t <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ewt�s f�u /ref o71- ald-d- NG <br /> J <br /> 003 - 030000 <br /> Property Owner's Mailing Address Property Location <br /> 6 9 9 8,0e.![dsh <<""�� Govt.Lot .3 <br /> City,State Zip Code Phone Number /,, /<, Section 7 <br /> F^ A v% YMA/ SS/d.3 &XI- 3N3- /G7rJ (circle one) <br /> II.Type of Building(check all that apply) Lot# T 4� N; R /.f E ore <br /> ®1 or 2 Family Dwelling-Number of Bedrooms d Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 2?Town of mar-le-Sopi <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System ;Z Replac rnent System ❑Treatlnent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com ponent/Device: (Check all that apply) <br /> JX Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Nlound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 30o S— �404 ti0o Ct1. 99t- 9i• ,c <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u <br /> New Tanks Existing Tanks u y a <br /> c- <br /> Septic or Holding Tank 7r0 7S0 <br /> Dosing Chamber S-O 4P Sd 0 <br /> VII.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 /> Plumber's Address(Street,City,State,Zip Code) <br /> 7>Go //, y �ar web.r71Y- 1�1 S`1t89� <br /> VIII.County/ e artment Use Only <br /> Approved ❑ Disapproved Pennit Fee 0 d Date Issued Issuing Agent Signa e <br /> ❑ Owner Given Reason for Denial s 37�, 3- /S' <br /> IX.Conditions of Approval/Re sons for Dis proval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I inches in size <br /> SBD-6398(110313) <br />