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County <br /> Industry Services Division RLA r r) fL <br /> II$ `r 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> m P.O. Box 7162 <br /> y A $ -v Madison, WI 53707-7162 fC�l�tL! <br /> Sanitary Permit Application Stater ansaction Number <br /> In accordance with SPS 383'21(2),Wis.Adm.Code,submission of this form to the appropriate goveminental unit <br /> is required prior to obtaining a sanitary pennit. 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(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 1�a7` ��S/ev o7 -ddk-d-`/O-141' i?O -d o3 <br /> pao - v/Na/ <br /> Property Owner's Mailing Address Property Location <br /> 3 y 37 GGt e v,o w etGe Ov Govt.tiot -5-W )UJ <br /> City,State Zip Code Phone Number '/, Section .30 <br /> W e6S/-tf✓ t_ .13 77 circle one) <br /> It.Type of Building(check all that apply) Lot# 7 T Glo N; R 14/ <br /> Ior2 Family Dwelling-Number ofBedrooms C7` Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use C1S'M Number ❑ Village of <br /> Town of -sue✓Y� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ Replacement S New System stem y ❑ Treatment/Holding Tank Replacement Only El 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 POWTS S stem/Com onent[Device: (Check all that apply) <br /> Non Preisturized 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(sf) Dispersal Area Proposed(st) System Elevation <br /> 6ev CM a <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks .- u y <br /> U in h v, LT U au <br /> Septic or Holding Tank 8'e Q <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 MPlMPRS Number Business Phone Number <br /> Pl uaber's Address(Street,City,State,Zip Code) <br /> 1776 a //V2 <br /> VIIL County/Department Use Only <br /> Approved ❑ Disapproved Permit Fez Date Issued Issuing Agent Si lure <br /> ❑ Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Gt/e l l 6.V s/71e a X' '/.'f 7 ',K t <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 trz s 11 inches in size <br /> SBD-6398(R0313) <br />