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tieti County el <br /> Safety and Buildings Division (f(wg/f <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> „ S P S, � Madison,W l 53707-7162 q/ i L1,3 <br /> Sanitary Permit Application State Transaction Number <br /> �/� <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit /"a 1",&,>5 /`G��G!�✓ <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 <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> L Application Information-Please Print All information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> 1670 Govt.Lot <br /> City,State Zip Code Phone Number ' 'y0. Section H7 <br /> �uc� Wl' S yf1 �S-3Z7 yB7/ —7 l <br /> T / N; R Q <br /> U.Type of Building(check ail that apply) Lot# <br /> 71 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of_ <br /> n <br /> I rTowaof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Repiacement system ❑Treatment/Holding Tank Replacement Only C1 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit 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/Device: (Check all that apply) <br /> TNon-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) I Design Soil Application Rate(gpdsQ Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> � r -7 ti `' 6 4y N.f rn9�si392, <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o' ? v <br /> New Tanks Existing Tanks y <br /> U <br /> a U in H fn u.C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber W <br /> VQ.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached platys. <br /> Plr00im <br /> s Name(Print) Plumber' gnature MPIMPRS Number Business Phone Number <br /> 1!7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2?Z2v `Sa r i &Vek,14r t,J; .5--18Y <br /> VRI.ComityfDepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 11 Owner Given Reason for Denial 5 ��� /) <br /> IX.Conditions of ApproveUReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a t lL-CTA'An i1Rt(Oh <br /> tam p A a t� <br /> SBD-6398(R. 11/11) "IV 14 2U1� <br />