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s,Eeaar.%,iy County <br /> �e��. °"� Industry Services Division � � ! <br /> �/' p 0 E Washington Ave <br /> r5 ` `� SCA N N E P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> % , j:1� Madison,WI 53707-7162��°F4 1-5'- 20 (5 . 00(2 5 <br /> �SIUN� <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 govemmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ,j ( C/ r//. e 0511 .--- G-Y- 6sGs-,0 _ <br /> v� <br /> Property Owner's Mailing Address Property Location <br /> 12(O C 60 '/L- Cr- Govt.Lot <br /> City,State • Zip Code Phone Number Ptil 'A, St''VI, Section Z4 <br /> (circle one) <br /> ,jan6 v1 �Ie • Ls) CW T N ; R( ( aorW <br /> H.Type of Building(check all t at app Lot# _ <br /> (Q-1-or 2 Family Dwelling-Nurtber of Bedr + Subdivision Name <br /> :l1 <br /> ❑Public/Commercial-Vescribe Use Block 4 <br /> ❑ City of <br /> []State Owned-Describe Use <br /> i _ ` CS M Number <br /> / ❑ Village of + <br /> 12�eG a-Town of,, K,`r k' <br /> Ili.T-ype-of Permit: (Check only one box on line A. Complete line B if applicable)•• <br /> A. tew System ❑ Replacement System ❑ Treatment/Holding Tank Replacerrfent Only ❑ Other Modification to Existing System(explain) <br /> B ` ❑ Permit Renewal �] Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ' Befpre Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> c�-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 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) / lOf•2- I cZJ,n7 I eX5.G. <br /> VI.Tank Info Capacity in �, <br /> Gallons °' o - <br /> Total 4 of Manufacturer s o U -. " <br /> Gallons Units ° °o ;: 2 ° . � A <br /> New Tanks Existing Tanks ,r n, j rn yr w C7 E <br /> Septic or-14efr#ir+gTank 1 '3 p U '�- 13U0 I 9.4> •r-G •®- ❑ CI ❑ <br /> Dosing Chamber 7 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ' ignature MP/MPRS Number Business Phone Number <br /> ia f tt,-, ..a,n / - 44-/` ,cg2e Li 74/ 603-757- 665-6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI G ,a, 2o.k rayPfTOA k). 535 7 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permr F ff Date p: ed Issuin e ign re� / <br /> ❑ Owner Given Reason for Denial $ � ` v-20!'� (/ <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 8 1/2 x 11 inches in size <br /> SBD-6398(R03/14) <br />