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County <br /> /' Nt„ Industry Services Division to Y ✓t e' <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box7162 AN -lq—lZ <br /> Madison,WI 53707-7162 <br /> � r 4851 <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 infonnation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. B <br /> I. Application Information-Please Print All Information !�i✓G la =S Ia.,c r• T.,A <br /> Property Owner's Name Parcet#' <br /> ?-ef-C✓ IvAi4roeve <br /> Property Owner's Mailing Address Property Location <br /> 3 8✓•oo 1i h a V ew TN r Govt.Lot &d-'7 <br /> City,State Zip Code Phone Number /, /,, Section <br /> G ill le #rn circle one <br /> 11.Type of Building(check all that apply) Lot F- T YA N; R A E or <br /> I or Family Dwelling-Number of Bedrooms 3 �� �j 'f Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of SGe <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Pennit 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 System/Component/Device: (Check all that apply) <br /> 19 Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ 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(gpdsf) Dispersal ea Required A Dispersal Area Proposed(st) System Elevation <br /> �v , _j- Argo0 Ct0a Sd.� a 9/- 3_ <br /> V1.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o a <br /> New Tanks Existing Tanksre <br /> v y <br /> c.U in V rn w U a <br /> Septic or Holding Tank CJ l//BQ� <br /> Dosing Chamber.. <br /> j 1 <br /> V11.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/MP RS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VII1.Coun /De artment Use Only <br /> Approved ❑ Disapproved Pennit Fee Date Issued Issuing Agent Signature <br /> � S 3-� i - i9 <br /> ❑ Owner Given Reason for Denial $ 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/3 x 11 inches in size <br /> SBD-6398(110313) <br />