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-" - County 1 <br /> Industry Services Division U04-‘4, <br /> ®$ 1400 E Washington Ave <br /> P Sanitary Permit Number(to be filled in <br /> P.O.Box 716 by Co.) <br /> S _ 2 <br /> Madison,WI 53707-7162 '3_2/ 70■)_ <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 is required prior to obtaining a sanitary ry permit. Note:Application forms for state-owned PO WTS are sub mitted 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(1X m),Stats. <br /> I. Application Information-Please Print All Information -err{-:Ud RA <br /> Property Owner's Name <br /> C1Parcel Parcel 4 <br /> Property Owner's Mailing Address <br /> ca <br /> rt I N( <br /> Property Location <br /> `-�1/f-l� , Govt.Lot <br /> ity, rate t I �M-1?1 Phone Number Nu '/., $W '/., Section 30 <br /> �[ (circle one) <br /> {) T N la; R 41, ar W <br /> II.r�Type of Building check all that apply) Lot a <br /> Ell or 2 Family Dwelling-Number of Bedrooms 3 I Subdivision Name <br /> ❑Public/Commercial-Describe Use Block k <br /> ❑State Owned-Describe Use <br /> ❑City of <br /> CSM Number ❑Village of <br /> 113b5' ©..Town of D-etikc.ld <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. GJ:New System ❑Replacement System ❑Treatment/Holding Holding <br /> Tank Replacement Only ; 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New I List Previous Permit Nwnber and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> KONon-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 /> �0 Rate)gpdst) <br /> x,44 lIZS )Izg g6.3' ci7.S. <br /> VI.Tank Info Capacity in t <br /> Gallons Total p of o' <br /> J <br /> Gallons Units Manufacturer : t✓ a <br /> I New Tanks Existing Tanks <br /> ° - F. r , % <br /> a;, in tii �.U c. <br /> Septic ortlt tEtng Tank I OM -- 1006 1 C re.bo 63 e' ❑ ❑ ❑ ❑ <br /> Dosing Chamber (per ---...' GOD I I ID&kswa. - ❑ ❑ ❑ . ❑ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pont) ).r ,'s Sigtta to / MPIMPRS Number Business Phone Number <br /> • �- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> qq 14 e41 Nl 14112, ID/. 535 off <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved P . e Date Issued <br /> g t <br /> ❑Owner Given Reason for Denial $ t,~ 6-4 00/� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 nz x 11 inches in size <br /> SBD-6398(R03/14) <br />