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County <br /> / ;. Industry Services Division <br /> �A B :t 1400 E Washington Ave Sanitary Pemtit Number(to be tilled in byCo.) <br /> SPs P.O. Box 7162 r�j�CJ r1t� <br /> _� ! Madison,WI 53707-7162 Xx/1� SIS r ) <br /> Kur►ac+� s�l v-15— <br /> Sanitary Permit Application State <br /> Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G O I/aJ (t/i ew <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 may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. e�b S.C. <br /> L Application Information-Please Print All Information <br /> Pro/perry Owner's Name / p7-Parcel <br /> 0 Vol <br /> � I-6-oa- V <br /> V'e N N l5 <br /> Property Owner's Mailing Address n Property Location <br /> 3dd0 wt.SGOgs�n 14,e I✓ Govt.Lot <br /> City,State Zip Code Phone Number —'/, Section 44 <br /> fr{dY✓ret- lti� S•yS'37 (circle one) <br /> 11.Type of Building(check all that apply) Lot T y/ N; R /S` E o <br /> i <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 1 C ❑ Village of <br /> V. -7 ? or 0 I at own of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ® New System ❑ Replacement System ❑ TreaunendHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POIATS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> J& Holding Tank ❑Other Dispersal Component(explain) _ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersat Area Proposed(st) System Elevation <br /> 300 <br /> V1.Tank Info Capacity in Total q of Manufacturer <br /> d <br /> Gallons Gallons Units L v $ <br /> New Tanks Existing Tanks v o e� 'Ti <br /> .-. C) in h <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS 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 7 60 //, 1S w��s�r� t�/1' _5 teyg 3 <br /> VV ill.County/Department Use Only <br /> g{I Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent SignaNre <br /> '\ ❑ Owner Given Reason for Denial S 37S7. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 12 x 11 inches in size <br /> SBD-6398(110313) <br />