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County <br /> Industry Services Division ��LX_r 01C£/ <br /> i7 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> ° sue lot 3 GST-19 40 <br /> Sanitary Permit Application S ta te 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 , l 'f J <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information J <br /> Property Owner's Name PParc el a_y Q_/(a_3 q G''/ <br /> Julie Nemc crop <br /> alga-- 0/1000:rt35 0� <br /> Property Owner's Mailing Address Property Location <br /> J -76 8 9 SfA f e Govt.Lot 1 <br /> City,State Zip Code Phone Number y, /,, Section d <br /> t v 0&61-ev Lay S Yn3 (circle one <br /> II.Type of Building(check all that apply) Lot# T �® N; R /6 E <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSIvi Nl­ r 8 rt S Village of <br /> -7gi1s <br /> 0 Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ,r New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B- El Permit Renewal ❑ Pennit Revision ❑ Change of Plumber70—wner <br /> Pen-it Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> XNon Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Nlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ 1 foldin Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information- <br /> Design Flow(gpd) esign Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 1 S-e D -7 to 11/3 6 yy 5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> New Tanks ExisdngTanks u Y d, R <br /> c`U cn m rn i,U a. <br /> Septic or Holding Tank p e t) 7 3�%a V <br /> Dosing Chamber.. . <br /> j <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/Ml Number Business Phone Number <br /> R,c/c Pop le s r� �� /c, 'Jr IdUss3j` 7/s=gb6 v/s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7719 f/ 3 S- 77/e 16,5-Y-Y�� lam_ S �/��i -3 <br /> VIII.County <br /> /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $� 3 <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> APPROVFD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in size <br /> SBD-6398(R0313) <br />