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r 1 • ••• .'� I.•• .— — ..... .0 I - uuury unq un paper not less tnan a 1/I. x 11 Incites In size <br />SBD -6398 (R. 08/14) <br />Industry Services Division <br />County <br />1400 E Washington Ave <br />9 14 K <br />Sgitary(tfl hi -filled in by Co.) <br />G/ <br />P.O. Box 7162 <br />Madison. WI 53707-7162 <br />�ermilmber <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 governmental 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 Services. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(l m , Stats. <br />1. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />i C: � <br />O / 23 <br />Property Owner's Mailing Address <br />Property Location ©/ <br />cty <br />Govt. Lot <br />y, Section <br />City, State <br />Zip Code <br />Phone Number <br />J <br />Qt <br />v <br />�,%� Q� <br />C. v <br />2 Q ircIe o <br />"T J( N; R E o� <br />li. Type o Building (check all that apply) <br />Lot # <br />0(1 or 2 Family Dwelling - Number of Bedrooms <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of / �1 <br />Town of L ) ►/o <br />CSM Number <br />III. Type of Permit: (Check only one box online A. Complete line B if applicable) <br />A. <br />❑ New System <br />;Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />❑ Permit Renewal <br />NilB <br />APermit Revision <br />El Change of Plumber <br />❑Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS 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 />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Dgsign Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Red (sf) <br />DispersarProposed (sf) <br />Sys Elevation <br />J` <br />Vt. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />c <br />New TanksExisting Tanks <br />° y <br />2 y <br />-p cci Ccs <br />Septic or Holding Tank <br />( OC <br />Dosing Chamber <br />® <br />i <br />Vt1. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Ter's Name ( rint) <br />Ci SS�s►C <br />Plumber'C'l�l re <br />MP/MPRS Number <br />- <br />Business Phone Number <br />2 <br />P's Address (Street, City, State, Zip Code) <br />T�) oz) C <br />VIII. Coun 1De artment Use 04ily <br />pproved <br />❑ Disapproved <br />Permit FeeD/ate <br />Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />$ )00 <br />IX. Conditions of Approval/Reasons for Disapproval , <br />W <br />r 1 • ••• .'� I.•• .— — ..... .0 I - uuury unq un paper not less tnan a 1/I. x 11 Incites In size <br />SBD -6398 (R. 08/14) <br />