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County <br /> Industry Services Division ,r3+%Y n-e <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O. Box 7162 <br /> r <br /> Madison, WI 53707-7162 ,q4 01 <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 fonns 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 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. 3 G ' 7eyC rt <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0A F7 5mi ko 0.7- oil-a- -6 P3 yo,oes - od 000 <br /> Property Owner's Mailing Address Property Location <br /> W( So 4,40,---t 4e.Mc Govt.Let 3 <br /> City,State Zip Code •� Phone Number y, /,, Section 1 <br /> ^7 Al S-S/17 T 1/O N; R /�vclE oreo <br /> II.Type of Building(check all that apply) u Lot# <br /> ® l or 2 Family Dwelling—Number of Bedrooms _( Subdivision Name <br /> B lock# <br /> ❑Pub lie/Conunercial—Describe Use <br /> ❑ City of _ <br /> ❑State Owned—Describe Use CSM Numbeyt ❑ Village of <br /> vo I Town of JA4usori <br /> lit.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System y ,X Replacement System ❑TreatmenUf[olding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersat Area Proposed(sf) System Elevation <br /> (a00 <br /> . 7 8S7 gG <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v v <br /> New Tanks Existing Tanks u Y <br /> 0 <br /> c U �n b cn ii V a <br /> Septic or Holding Tank /at S-6AV <br /> t�o /YS-e <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 MP/MPRS Number Business Phone Number <br /> R/ 6/4f }/u /<�h s /Ze�4 ,4 7/s=8G6 -e4AS-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 017740 N••. , 3.�- W t�✓��rr � S`it�93 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Dale Issued Issuing Ageft Sighature <br /> Ll Owner Given Reason for Denial $ 3 76'- DO 4-_/7 <br /> IX.Conditions of Approval/Reasons for Disapproval ��� <br /> A,o a/Pt! <br />