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County <br /> Industry Services Division a"Vh� <br /> = B 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> r r Madison, WI 53 70 7-71 62 <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 YvFG <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. �'6 /�O� C <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# - s- ys- <br /> 13rAet G1tiS t��Sovt c��•�vd'a 87_©/3060 <br /> Property Owner's Mailing Address Property Location <br /> // 770 L/7yli <�I rd e Nr Govt.Lot <br /> City,State Zip Code Phone Number %, %, Section �g <br /> S t, M I C A'tt-' M Al Sr-3 76 t"1 circle one <br /> II.Type of Building(check all that apply) Lot# T y N; R 7S E o& <br /> Od t or 2 Family Dwelling-Number of Bedrooms 3 3 V-7 !n f Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number Village of <br /> ®Town of JoCG k s0 n <br /> III.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. El 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 System/Component/Device: (Check all that apply) <br /> N'on Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑FlaPdmgTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dis a saI/Treatment Area Information: <br /> Desig rF?ow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o t:, Y cd <br /> c`U C/3 m kC7a/ <br /> Septic or Holding Tank �ej-.5-0 /0, -v r, )-A to ✓ /� <br /> Dosing Chamber.. ) <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,/ MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -7 3-5' 11/-e 6 s?e tV <br /> VIII.Coun /De artment Use Only r -115 <br /> Approved ❑ Disapproved Permit Fee i Date Issued ;TI <br /> ssuin gen gn <br /> ❑ Owner Given Reason for Denial $ �Z� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ORIGINAL APR 8 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in 11 inches in si UMett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />