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County- <br /> Industry Industry Services Division l�L"Yoe <br /> .fl S " 1400 E Washington Ave <br /> , " �') 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box7162 d�lJ _t9_t� <br /> Madison, WI 53707-7162 <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 goverunental 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(t)(m),Slats. 511��J y / <br /> I. Application Information-Please Print All Information 777✓ee`71. 4- lc e' <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> 3 S' i' �� Govt.Lot <br /> City,State Zip Code Phone Number <br /> /, Section / <br /> N C k-A Al j—5 3 Q 3 (circle ones, <br /> II.Type of Building(check all that apply) Lot# T q C) N; R 1% E oz� <br /> l or 2 Family Dwelling-Number of Bedrooms c �E Subdivision Name <br /> Block# F \,J", �,L Vv <br /> ❑Public/Cotrunercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of J <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System JWReplacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pen-nit Renewal ❑ Pennit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> ArNon-Pressurized In-Ground ❑ Pressurized In-GCOLmd ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ HoldmgTank ❑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 /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks v <br /> 0 <br /> a U v n [ C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> n <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 NIP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 76 <br /> VIII.County <br /> /De artment Use Only <br /> pproved ❑ Disapproved Permit Fee Date Issued q Iss g ent Sigma e <br /> ❑ Owner Given Reason for Denial $ 3- 1 I I / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> S"r— 4jr- S/ Sc.`f�o-c,�t 4Y pis �lv f <br /> Attach to complete plans for the system 11 344 t gun, o er not less than 8 in s 11 inches in size <br /> SBD-6398(Rn313) <br />