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0 <br /> County <br /> ` „. Industry Services Division /3u.rK — <br /> , � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> pi P.O. Box 7162 <br /> Madison, WI 5370 7-7 1 62 <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 <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 'A t-(90-7 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. S <br /> 01 <br /> 1. Application Information—Please Print All Information �' le), <br /> Property Owner's Name Parcel# 3 e/ 19 -31/3 01 <br /> e Fic �reA P,-e o,7 —t7Nb " 060— A 1/0607t z 1l� <br /> Property Owner's Mailing <br /> �Address Property Location <br /> -/ p-f ( /7 1 /ro /'Zd Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 3 <br /> �J30� � Sy 01(b circle one <br /> II.Type of Building(check all that apply) Lot# T N; R E ot� <br /> Ix 1 or 2 Family Dwelling-Number of Bcdrooms Jk Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> D'Town of Marsh (a a7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System 5(Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. El Permit Renewal El Permit Revision El Transfer to New <br /> Before Expiration Owner <br /> IV.lype 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 /> ❑ Holdma Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil.Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 f .S" Pooh 1 (QVD 1 9z1,3 <br /> VI.Tank Info Capacity in Total #of Manufacturer V c <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> 0 <br /> C. <br /> 0 in y rn w 0 a. <br /> Septic or Holding Tank <br /> Dosing Chamber.. .Cif 5�(9 <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 MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -7760 A.t 3`5 - We6,e , ll t,� 5-�6rci3 <br /> VIII.Coun /De art ent Use Only <br /> )�Approved ❑ Disapproved Permit Fee Date Issued e, Issuing Agent,Signa¢_W <br /> ❑ Owner Given Reason for Denial $ 3� J / `/V <br /> IX.Conditions of Approval/Reasons for Disapproval D =�� <br /> MAY 0 2 2019 <br /> Attach to complete plans for th s em and su gt4Q the Co ty only on paper not less than 8 1/2 x 1 e <br /> ZONING <br /> SBD-6398(110313) —/"-i9 <br />