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�. :.• _ <br />-„� <br />Industry Services Division <br />County <br />%3u rn G” <br />t it <br />1400 E Washington Ave <br />9 <br />Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. <br />C, <br />Madison, W1 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />~� <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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 <br />Parcel #�/G .r6� oY -3 d - Ua0 <br />O10"A" <br />l7Gt M Oc or io6 e s <br />07- <br />_ 011/ore <br />Property Owner's Mailing Address <br />Property Location <br />_73.5-6 Hl1. o(rh G« led <br />Govt. Lot <br />S �,�/ y SV1%/<, Section <br />City, State <br />Zip Code <br />Phone Number <br />hs f"< ✓ <br />webs <br />�" (� QfI_ <br />!/ <br />circle one) <br />T 1 o N; R /� E o& <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />❑ l or 2 Family Dwelling — Number of Bedrooms <br />3 <br />Public/Cotnmercial- Describe Use 80.kG $ 110 <br />Block # <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />Town of 6019 1A. <br />CSM Number <br />�, <br />x/,11 70 <br />I1I. Type of Permit: (Check only one box on line A. Complete line S if applicable) <br />A' <br />New System <br />❑ Replacement System❑Treaunent/Holdins <br />Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />❑ 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 />❑ Non -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) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />VI. Tank Info <br />Capacity in Total # of <br />Manufacturer <br />Gallons Gallons Units <br />o <br />y <br />New Tanks Existing Tanks <br />v <br />n <br />o v E Y <br />U cn y rn <br />v a <br />z U n <br />Septic or Holding Tank <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 />NIP/MFRS Number <br />Business Phone Number <br />l2_111clz <br />JG'r ..a <br />),As <br />Plumber's Address (Street, City, State, Zip Code) <br />,o� 774 0 ILIX -7.5— <br />VIII. Cour /De artment Use Only <br />Approved <br />11 Disapproved <br />Permit Fee <br />$ d <br />Date Issued <br />Issuing Agent Signature <br />Owner Given Reason for Denial <br />T76• <br />/Q - -1Q' <br />IX. Conditions of Approval/Reasons for Disapproval n <br />NO S1a-c �Wr'.ovaC �irmolT�yCor DSPS /A_9wxro Ar/17 e, • ( ! ��� <br />IPPRII ' Mogi c si�� <br />Attach to complete plans for the system and submit to the i1t�. L_/ <br />OUNN TT COUNTY <br />ZONING <br />SBD -6398 (1103 13) <br />