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✓.s !' Coun <br /> Industry Services Division <br /> 1400 E Washington Ave <br /> a' S 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> 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 <br /> is required prior to obtaining a sanitary pennit. 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 a7 1 a <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information J O <br /> Property Owner's Name Parcel# <br /> P m1 o7- 0&,, —MO !b dsr 'f od <br /> /Zle-�tar'4 'A1,41G1,V 0o0 p/lODO 13G� <br /> Property Owner's Mailing Address Property Location <br /> b V 78 4 i t Rd- Govt.Lot <br /> City,State Zip Code Phone Number <br /> /+, /<, Section <br /> U/e.bs�{ wig .5"Y89,3 71�- 791 -t�o,23 <br /> cucle one <br /> II.Type of Building(check all that apply) Lot# T YO N; e /� E or� <br /> tor2 Family Dwelling-Number ofBedrooms <br /> '3 Subdivision Name <br /> Block# <br /> ❑Pubhc/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Townof Qa Kll.h4Q, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Q New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Chan, ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal Pen-nit Revision �e of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑ Hgldin,�Jaak ❑Other Dispersal Component(explain) ❑Pretreatinent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 4,S'o s' gav �ioo 9 Jr-0 V. qs: <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks <br /> O "4r r, a,U oo � u U a <br /> Septic or Holding Tank <br /> Dosing Chamber.. <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 ,/ NIP/MPRS Number Business Phone Number <br /> �G I G/G fj d A I..f �C�'�^+� TT d�8e�/ 7/�� rid'�//�-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77(eO �., 3.5— W-7— S711 S 93 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Pennit Fee Date issued suing Agent Signature <br /> ❑ Owner Given Reason for Denial <br /> 375 3 6 19 <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 1/2 s 11 inches in size <br /> SBD-6398(R0313) <br />