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a r County <br /> Industry Services Division i3m,YA ls± <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 (o 4 b 66(o <br /> ''• i'.,_`: ;� 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 53�j� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. (�e Rd, <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel� <br /> F >4r►,j /y%�/ /?c% TrH�T - O//moo <br /> Property Owner's Mailing Address / Property Location <br /> .S8�o 1 Cr't'C K Ua11 Cy Govt.Lot gr <br /> City,State Zip Code Phone Number %, /a, Section b <br /> t /t.70, rn N 15�013 � circle oneG OrT N; R / E or <br /> 11.Type of Building(check all that apply) ? Lot# <br /> or 2 Family Dwelling—Number of Bedrooms J 3 Subdivision Name <br /> Block# <br /> ❑PubEc/Commercial-Describe Use <br /> ❑ City of <br /> ❑ CSIvI Number Village of <br /> State Owned—Describe Use <br /> Town of Je,c A-5 <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Chan4e of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> ' e,of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> ',:NW zed rn-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> El €fa4Wank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VOK ersal/Treatment Area Information: 1. <br /> D6siF ow(gpd) Design Soil.Application Rate(gpc!4 Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> • G�So , .� gao gao 9Y.S q3�s 9d.s <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> U <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o B <br /> c 0 rn m inn G%C7 P. <br /> Septic or Holding Tank X <br /> BIiO �06a 1 Sn/=il�rAyv✓ <br /> Dosing Chamber- . J <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 NIP/N[PRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> p �x 3.J7 lw.c�/rl brjS <br /> VIII.Coun /De artment Use Only <br /> "proved ❑ Disapproved Pe�' �' Date issued urn g tSigna <br /> ❑Owner Given Reason for Denial 1 l/q '-)/ I <br /> IX Conditions of ApprovaUReasons for Disapproval <br /> OCT 2 8 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s I inches to size urnett County <br /> Land Services Department <br /> 0 <br /> ¢Rn_Atoe <br />