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county <br /> f-''�! ',.i <br /> �, .�.� Industry Services Division <br /> 'Xi n 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 ;5 ig„) 2 c� <br /> ' % 4 - ,r-:, 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 governmental unit -3/ o I y'1 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS 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. 7 /s <br /> I. Application Information-Please Print All Information r>tin *r e /?or <br /> Property Owner's Name Parcel# <br /> 07- a1.8'J, -341 -o.3,S as <br /> OeApi sa S�ct��r vo,A- od8o06 <br /> Property Owner's Mailing Address � _ D Property Location <br /> 7, ,F ) in d ro Ter <br /> �a✓K 1 �Of Govt.Lot d-.3 <br /> City,State Zip Code Phone Number , 3 <br /> /, /<, Section <br /> (circle one) <br /> T 39 N' R /(, EQC <br /> 11.Type of Building(check all that apply) Lot# <br /> t or 2 Family Dwelling-Number of Bedrooms pl Subdivision Name <br /> Block# <br /> ❑Public/Connmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V. d 5 y krTownof MK$ry6.i <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System ;X Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit 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/Con onent/Device: (Check all that apply) <br /> Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade f�Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding;Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> tiso �. o vso yso 9 7. .� <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units ; o <br /> New Tanks Existing Tanks o v 6 R <br /> c 3 n n w U C <br /> Septic or Holding Tank <br /> Dosing Chamber O O t <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PONVCS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> IF,e-/G "Z/o �6 i h > <br /> Plumber's Address(Stree,City,State,Zip Code) <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Signature 'I ' <br /> $ <br /> ElO tiE fiL� <br /> Owner Given Reason for Denial 3 7-S� ^ /D <br /> IX.Conditions of Approval/Reasons for Disapproval �E �/,� <br /> ]E3 <br /> 4PPROVED <br /> OCT 17 2018 <br /> Attach to complete plans for the s em and submit to the County <br /> tiCounty only on paper not less th 8 t/Z s 11 inch siWET.T.COUNTY <br /> /�.IA dl &-C/-'/? ZONING <br /> SBD-6398 (R0313) +.1 —J4.1.#' <br />