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ry County <br /> Industry Services Division s r n-e-*- <br /> y` Is 1 1 1400 E Washington Ave Sanitary Permit Number(to be filled n by Co.) <br /> ps tf P.O.Box 7162 QQ <br /> Madison,WI 53707-7162 259 le- <br /> -5. <br /> le <br /> -5. <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 PO WTS are submitted to Projcct 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(l)(m),Stats. <br /> f. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Vernon o44sk,,.14 _ o/dbo0 <br /> Property Owner's Mailing Address Property Location <br /> ���� C�c.� ¢.^�SeN /2cP• Govt.Lot 0) <br /> City,Sl//ate Zip Code Phone Number y,, '/, Section 7 <br /> W QWS�<✓ GST S`� 893 7/f- a _$,1 S'� (circle one <br /> II.Type of Building(check all that apply) Lot# T 38 N; R 9.5 E o� <br /> ❑ 1 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 /> Town of Z4 t'acz <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System �Replacement System <br /> ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber <br /> ❑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 /> �[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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sir System Elevation <br /> foo S Gao (00 �� 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks c <br /> 0 <br /> — U y 17 Cr. L 4 <br /> Septic or Holding Tank 7.J 7b-O <br /> nosing Chamber BOO $®U <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 MRMPRS Number Business Phone Number <br /> Tele //a 141 h j /?-� d S8S/ 7ir8G6- '��s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,VI I.Coun /De artment Use Only <br /> t <br /> Approved ❑ Disapproved Permitt7Fee O Date Issued Issuing Agent T e <br /> ❑Owner Given Reason for Denial - S /5- -- 12-M -1Y <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 s 112 x 11 inches in size <br /> SBD-6398(R0313) <br />