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County <br /> ! `* Industry Services Division 34 rn t <br /> jk,".v Q 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P �'i P.O. Box 7162 <br /> Sf Madison,WI 53707-7162 <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 60L.A. /' ` <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 ^y,�5'O <br /> purposes in accordance with the Privacy Law,s. 15.04(t)(m),Stats. C <br /> 1. Application Information-Please Print All Information ,1 3�eoees T Z. <br /> Property Owner's Name Parcel# �s p Y, , /f <br /> 67-ory-,l-30- <br /> JeLpi4 E+h.evfin J e nj e (mgr ol7ooa <br /> Property Owner's Mailing.Address / Property Location <br /> [JOWen -4 GaNe Govt.Lot <br /> City,State Zip Code Phone Number y,, /., Section y <br /> W&0;bur Lam Mtv SS�,tS (circle one <br /> If.Type of Building(check all that apply) T 3� N; R�>.�F.o <br /> p Lot# <br /> ' 1or2Family Dwelling-Number ofBedrooms s/ -7 Subdivision Name <br /> Block# s <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of J <br /> A Town of LQ �O 114&e- <br /> IIL 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. ❑ Permit Renewal ❑ Permit RevisionList Previous Pennit;Number and Date Issued <br /> ❑ Change of Plumber 11 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onenVDevice: 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 /> gHolding 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) llispersal Area Proposed(st) System Elevation <br /> `— <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks 2 Y a <br /> Septic or Holding Tank d step C) a s%(� /•�f•� X <br /> Dosing Chamber <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 Iv1P,'MPRS Number Business Phone Number <br /> le f.o r Jc � afd'�S/ 7�S= 8�G-4.5'7 <br /> Plumber's.Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> VApproved ❑ Disapproved Permit Fee QDate Issued Issuing A ent Signature <br /> ❑ Owner Given Reason for Denial <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 8 U2 s 11 inches in size <br /> SBD-6398(110313) <br />