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i <br /> County(� <br /> ` ;� Industry Services Division /,tn r n-1 <br /> 1400 E Washington Ave Sanity Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <br /> ,t _ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit ar 9 1'97y� <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. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> -37-o#ao-ayouRo _0/0b0-d-am 3 -O <br /> d <br /> o//om <br /> Property Owner's Mailing Address Property Location <br /> 7'76 0 rc.y Govt.Lo <br /> City,State Zip Code Phone NumberAI , <br /> /.,S b, Section <br /> WeL,f <r �.�1/� st/�G}3 -vs'-946- Gl/S7 (circle one <br /> T VD N; R E o <br /> U.Type of Building(check all that apply) Lot# /(v V <br /> ❑ 1 or 2 Family DwellulIg-Number of Bedrooms Subdivision Name <br /> i <br /> _ Block# <br /> 19Pubtic/Commercial- escribeUse ��/'tGt�sLtOrQ ❑ City of <br /> z— <br /> ❑ State Owned-Describe Use CSM Number �❑l Village of <br /> Kl Town of ae�IG let <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System I ❑ Replacement System ❑Treatment/I folding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pen-nit Renewal ❑ Permit Revision ❑ Change of Plumber L1Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiratiorj Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Nan-Pressurized In-Ground ❑ Pressurized In-Ground ❑ AL-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 /> 6 7s . 7 1 9tsS lot 0 0 <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> u <br /> Gallons Gallons Units '` o <br /> New Tanks Existing Tanks v c u m ce <br /> Septic or <br /> #6let,n �S4.&yt I AX70 dS76 / <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MPf/MPRS Number Business Phone Number <br /> /76 '�,n S !7" aP,s� 7•✓�= -ell s-T <br /> Plumber's Address(Street��,//City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit <br /> -Fee D Date Issued Issuing Agent Signa re <br /> ❑ Owner Given Reason for Denial $ 3 <br /> IX.Conditions of Approval/Reasons for Dis/apprroval / / �� ) <br /> /�oGdiN9 qw 76 �e 4)S IG( b—;7 /t/OiU ,D6/YI PSFI� A),4.5 le J41A �el� <br /> ler A/.Z D�✓R J017-Dam t' <br /> i Attach to complete plans for the system mud submit to the County only on paper not less than 8 Ir x 11 inches in size <br /> SBD-6393(R0313) <br />