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Coun <br /> Industry Services Division k r n t <br /> ! �< 0 x 1400 E Washington Ave Sanitary Permit Number(to be Filled in by Co.) <br /> ' SSPS E P.O. Box 7162 1: 11 � <br /> ' r" 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 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 a 4 j1Q 3 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information C/A*1 �+�G �✓ <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> ty qd AvC /lJ Govt.Lot <br /> City,State Zip Code Phone Number y, y., Section J'-r <br /> �l �t4fa.t Gl fYl/✓ SSY`f b It- o)[f 0' �'t 7Scircle one,�,,7 <br /> T 39 N; REo6 <br /> II.Type of Building(check all that apply) Lot# <br /> a ! <br /> 1 ort Family Dwelling-Number of Bedrooms Subdivision Name t <br /> Block# - ,g <br /> ❑Public/Commercial-Describe Use <br /> ❑ 'City of <br /> ❑State Owned-Describe Use CSM Number 11Village of <br /> 91 Town of Y t4 OF M <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System � Replacement System <br /> ❑TreahnenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit RevisionChange of Plumber ❑Penni[Transfer to New List Previous Permit Number and Date Issued <br /> ❑ <br /> Before Expiration Owner <br /> IV.Type of POw"TS System/Component/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 /> 2 Holding Tank ❑Other Dispersal Component(explain)_____ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> -- <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D c$ <br /> T"ew Tanks Existing Tanks u v = s m m <br /> Septic or Holding Tank 1�0 QOQ J t f <br /> Dosing Chamber It <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 /> , A// - vis- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ® Approved ❑ Disapproved Permit Pee Date Issued Issuing Agent Signatur <br /> Il ❑ Owner Given Reason for Denial S ;7:5-00 <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 a t/2 x 11 inches in size <br /> SBD-6398(R0313) <br />