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'='•+ ` '*i pti County <br /> Industry Services Division i3�y yy <br /> flv- <br /> 1400 E Washington Ave SanitaryermitNumDer(0 be tined in by Co.) <br /> pS �l P.O. Box (al`!1'c �1 <br /> Madison,WI 53707-7162 J T <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 govermnental 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 Servies. Personal information you provide may be used for secondary �'1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. `/ Q(1® /qy <br /> L / <br /> A P Application Information- l /"Please Print All Information /ah S C0.at L� �✓Fv� <br /> Property Owner's <br /> ,�Name i j-7 O��.s a-�� ��L/� If 7—S <br /> /7 U6 U( llvrSO r� /S-- 04.0--qA6 nG�P <br /> Property Owner's Mailing Address Property Location <br /> j Ci/QS I7A0Se&4.,1 L K 'r Govt.Lot <br /> City,State "Zip Code Phone Number S6, X, Section -7 <br /> 404v/6U rY W-5- s-yg3 p (cicleone <br /> II.Type of Building(check all that apply) Lot# <br /> T �� N; R / L otV <br /> I or 2 Family Dwelling-Number of Bedrooms Q Subdivision Name <br /> Block it I//-tlFt <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of �^ <br /> G67� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) Town of J <br /> A, New System <br /> y ❑ Replacement System ❑Treatment/Iioltling Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Sys tern/Com onent/Device: Check all that apply) <br /> a Nan-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ 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(so Dispersal Area Proposed(st) System Elevation <br /> 44 0 . 7 6 4r3 4 4" 9o(, 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks u Go v Y ? n <br /> T `3 <br /> Septic or Ilolding Tank /ds-0 / y f t,/V rA yf e <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 MP/MPRS Number Business Phone Number <br /> lirele y kir,� / /� etdS"�S / 7i1I=t?66-41/5-7 <br /> Plumber's Address(Street,City,State,Zip Code) / T <br /> 7/'s O 4 J J !A/ e�S7fY/ WL S�S9� <br /> V1I1.Coun /De artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date Issued Iss in Agent Sjtertutyre <br /> 375 b- a�m lj�l✓1lA/✓ <br /> ❑ Owner Given Reason for Denial /w <br /> IX.Conditions of Approval/Rensons for Disapproval <br /> Attach to complete plans for the system and submit to the Cowry only on paper aot less than fl Vz s 11 inches in size <br /> SBD-6398(R0313) <br />