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<br /> ��� •"'pti County
<br /> `� Industry Services Division Vin v I-, •e?`f
<br /> r (toby
<br /> ,.��rt y � �� 1400 E Washington Ave SanitaryPermit Number be tilled in Co.)
<br /> 0 _' r'1 P.O. Box 7162
<br /> v.,„%_., -1 , ' rs1; Madison, WI 53707-7162 �a -a2i 3
<br /> State Transaction Number
<br /> Sanitary Permit Application Lf2.01,21
<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 -7J-4.4.3 "-It&n G R,d
<br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats.
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name rcel# ,4a ,4_3j -.-off-'at,6
<br /> 0Pa7b}O-a-
<br /> Dettf5 //r e-res 0rS-ao0 If NW-
<br /> Property Owner's Mailing Address Property Location
<br /> (1 Y 3 3 `5-62r-11 - 'f• it/ Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> �Sr7�� /, /<, Section 3S
<br /> 6.e. ( . k"1/..4-% d circle one
<br /> T 4/O N; R I& Eafy
<br /> II.Type of Building(check all that apply) 3 Lot#
<br /> 1P l or 2 Family Dwelling-Number of Bedrooms Subdivision Name
<br /> B lock#
<br /> ❑Public/Commercial-Describe Use ❑ City of
<br /> CSM Number El Village of
<br /> ❑State Owned-Describe Use
<br /> "Town of
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A.
<br /> ❑ New System ,i Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other lvloditication to Existing System(explain)
<br /> B ❑Change of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued
<br /> ❑ Pennit Renewal ❑Pennit Revision
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> M Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
<br /> ❑Holdin Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation
<br /> 4-1,s`0 . S 9., 9 ea 9 y• 9 9,i.l 93 a1
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units v o ,�,
<br /> New Tanks Existing Tanks F o 4, Y L m ti
<br /> a. U cn ti rn u.(.7 a.
<br /> Septic or Holding Tank
<br /> —
<br /> lac 0 /D,f"d / v H f,'(44-401.41✓ VDosing Chamber.. 1 •),
<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/MPRS Number Business Phone Number
<br /> t c k 114 ,k 11/4 f ja,t. , re17/,, ' ' ))7,5'57 ->/..5---, (66-9/5 7
<br /> Plumber's Address( treet,City,State,Zip Code)
<br /> ---d 77Gd .sit,. s- �v�&J/ -- S `tf S3
<br /> VIII.County/Department Use Only
<br /> Approved ❑ Disapproved
<br /> Permit Fee Date Iss ed I Agent Si_ attire i /
<br /> 00
<br /> ❑ Owner Given Reason for Denial v/7/ lO // AM �ir,L--/, `�(EaV��';�
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> vt,t,A54 bc- 1'1.9, ?yd, 93.2 or
<br /> APPROVED No low, 4.1 .cle, bn _ 1 OCT 1 1 2019 J
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tP s l I inyhe rviCes Department
<br /> SBD-6398(R0313)
<br /> ::k,* 011;`7(r l 3 `I36
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