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Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 11 inches in size <br />SBD -6398 (80313) <br />Industry <br />Industry Services Division <br />County <br />County <br />0 Y,� <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />}' <br />P.O. Box 7162 <br />J AVv-IB-�� <br />F% <br />Madison, WI 53707-7162 <br />/ � 76� <br />LIQr <br />C9 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate pvemrnental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />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(l)(m), Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel #O"1 <br />W1 FN -e <br />oy - 060 - 611100 <br />Property Owner's Mailing Address <br />Property Location <br />5,5ly ��� V �✓ � � <br />Govt. Lot <br />/, y,, Section 36 <br />City, State <br />Zip Code <br />Phone Number <br />circle one <br />T W N; REoC <br />11. Type of Building (check all that apply) <br />Lot # <br />❑ l or 2 Family Dwelling - Number of Bedrooms ' <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />El State Owned -Describe Use <br />❑ Village of <br />CSNI Number <br />X Town of wl S S <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A'V5 <br />New System y <br />El Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />B. <br />ED] Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />i on-Pressii=ized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound> 24 in. ofsuitable soil ❑ Mound <24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis al/Treatment(gpd) Area Information: <br />Design Flowers <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />/So 1 <br />.7 <br />at i 6 <br />S3. ,s— <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units � t <br />o' " <br />2 <br />New Tanks <br />Existing Tanks <br />0 <br />v 6 <br />Septic or Holding Tank <br />.✓ `10 <br />7- <br />stlt� � .Lh �`��vaf'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) <br />Plumber's Signature <br />Nmber IP/MPRS Nu <br />Business Phone Number <br />�L 161 /c �� s <br />'/ <br />4_� l <br />o�J,sgS <br />lis- 866 -�/ �-s7 <br />Plumber's Address (Street, ity, State, Zip Code) <br />4 7 7 0 le __!Z� ty X $7(V <br />Coun /Department se Only <br />Xpproved <br />El Disapproved <br />❑ Owner Given Reason for Denial- <br />Permit Fee <br />Date Issued <br />[ss ing Agent Signature <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 1/2 s 11 inches in size <br />SBD -6398 (80313) <br />