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County <br /> / M ��3�,t =201 <br /> ings Division 13fAr H e� <br /> O$ <,., tve., P.O. Box7162 Sanitary Permit Number(to be filled in by Co53707-7162pp r� r�59 9 ! ,G 9 <br /> Sanitary PP Permit Application State Tction Number l In accordance with SPS 383.21(2),W is Adm.Code,submission of this form to the appropriate governmental Rel unit tJ1 sCw Z <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned PO WTS are submitted to Project Address hi'different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary _ <br /> purposes in accordance with the Privacy Law,s. 15.04(l Hurt),Stats. OA 3 Ca <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#o7-oa Q'.A-40 W 4 a 3'-5- <br /> 0 <br /> 'S0 P-, 6: <br /> p5roof-ol7o00 } oll000 <br /> Property Owner's Mailing Address Property Location OZ5-4113-°2-720 <br /> 0°eP Iglu✓stL Lh. Gov[.Lo[ 1 _ <br /> City,State Zip Code Phone Number y,, Y,, Section /.3 <br /> �IH to-Iiia 14A /yN S'S3 4S T YO N. R /�(circlE mi5P <br /> 11.Type of Building(check all that apply) f+f Lot# '(Y+'" <br /> I or 2 Family Dwelling-Number of Bedrooms o 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use Cl City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V,i3 r? /d-14 To.of SGO <br /> 111.T}pe of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ❑ New System <br /> Replacement System ❑ Treatmen'Holding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Pernit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Deyice: (Check all that ati <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inofsuitable soil ❑ Mound<24 inofstumble soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed Uf) System Elevation <br /> /d 00 . 7 1714 7)6� <br /> VI.Tank Info Capacity in Total go Manufacturer <br /> Gallons Gallons 1 Units <br /> New Tanks Existing Tanks - - o <br /> Septic or Holding Tank S7o dr�0 / SKS M/ <br /> VII. Responsibility Statement- 1,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 /> o�`�n 7/5--BGG` y/5^7 <br /> Plumber's Address(Stre t,City.State,Zip Code) <br /> VIII.County/Department Gse Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Age nature <br /> ❑ Owner Given Reason for Denial <br /> g3z5 <br /> I\.Conditions of Approval/Reasons for Disapproval <br /> lJsTe 54„1 Cells W1 1) be £e4. 6 o(c .e/lefq. <br /> Attach to complete plans for the system and submitto the County only on paper not less than 8 1/2 a 11 inches in size <br /> SBD-6398(R. 11/11) <br />