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ra <br /> f 1 Coun <br /> r'y i Industry Services Division <br /> 41 P y' 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P P.O. Box 7162 <br /> r gArJ— I" <br /> Madison, WI 53707-7162 <br /> "vl <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 govermnental unit <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 S�fa� (*J <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. q if <br /> I. Application Information—Please Print All Information �I tG+ �J��ras en /�(� <br /> Property Owner's Name ) Parcel# <br /> rn M r l�1"Gti,vI Z �7•_b,�ul®�'� .. �..�© c��'O ,�yl <br /> Property Owner's Mailing Address Property Location <br /> s-�/Ie l510 s - ) <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section <br /> MM reek°-a /0 Al S-4�b f circle one <br /> Ii.Type of Building(check all that apply) Lot# <br /> T 91 N; R I' E of <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms P 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> Town of <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Moditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Pennit 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 /> Nan Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ HoldmT Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Information: <br /> Design FIow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> Imo LJfln 9l1 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o <br /> C.U �7, h rn i C7 n <br /> Septic or Holding Tank �O t- o j�1 j / �h f �+Q b✓ <br /> Dosing Chamber. J <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PONVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> ,72°aG ?7Iv In ,t ple�c 8�v1�- 41/j-;;, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 h 3� Z <br /> VIII.Coun /De artment Use Onl <br /> 4pproved El Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial 7 3 D.� �, �� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED MAY 2 2 201 <br /> Attach to complete plans for the system a on paper not less than 8 l/2 s l l inches,iq,S�N66"��j(( E�COUNTY <br /> ;::Zty <br /> liC ZONING <br /> SBD-6398(R0313) lv�L 9 <br />