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mach to compiece pians tar the system ana sunmit to the County only on paper not less than 8 1/2 x 11 inches in size <br />SBD -6398 (R0313) <br />County <br />3V ✓''� <br />Industry Services Division <br />i . � <br />if :SSanitary <br />1400 E Washington Ave <br />Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />6M-19-01 <br />� <br />>� <br />Madison, WI 53707-7162 <br />a ��I <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govemmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />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. <br />1 r <br />76O 3y C V/y <br />I. Application Information - Please Print All Information <br />Property Owner's Narne <br />Parcel # 3 4 FY -0ev <br />r•eA q +- Awn-e�ftom <br />70°� <br />Property Owner's Mailing Address <br />Property Location <br />Q <br />� -7 AA b �''t { <br />o' �/ C C P, <br />Govt. Lot <br />Section 8 <br />City, State <br />Zip Code <br />Phone Number <br />� u h K ✓`r �✓y <br />p <br />s� O ,3 0 <br />-7/,57' - d� � " 90 Y41 <br />T 3 [ N; R � �jcircle one) <br />E or W <br />II. Type of Building (check all that apply) <br />Lot # <br />13 1 or 2 Family Dwelling - Number of Bedrooms 3 <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />Town of yfii -e if vi 0 ✓t <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />Replacement System <br />❑ Treatment/Holdina Tank Replacement Only <br />e <br />❑Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type POWTS System/Component/Device: Check all that apply) <br />-of <br />❑ Nbn Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />Z Holdino;Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis a i /Treatment Area Information: <br />Desigii Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />mss- v <br />_ <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />a o <br />New Tanks <br />Existing Tanksu <br />y <br />U fn <br />rn w C7 a <br />Septic or Holding Tank <br />-7S—O <br />d0(> � <br />(iv / s'S 't ✓- <br />X <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber'sName (Print), <br />ZI <br />Plumber's Signature <br />MP/MFRS Number <br />Business Phone Number <br />I G/7///G 0 l<i.1 _$ <br />;,A <br />%/S=Oj�_- y/S 7 <br />Plumber's Address (Street, Nty, State, Zip Code) <br />7 7G <br />III. Coun /De artment se Onl <br />Approved <br />❑ Disapproved <br />Pen -nit <br />Date Issued <br />Issuing Agent S atur <br />11 Owner Given Reason for Denial <br />$ 2/ s • 00 <br />�- 12 -1511 <br />IX. Conditions of Approval/Reasons for Disapproval <br />mach to compiece pians tar the system ana sunmit to the County only on paper not less than 8 1/2 x 11 inches in size <br />SBD -6398 (R0313) <br />