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;r:",iene rxii,:-, County ,, 'r Industry Services Division 4, ,-- 3�', D$p ,,• liy'� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) P.O. Box 7162 y f S f�i' Madison,WI 53707-7162 '1. vS70N PV r' Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I. Application Information—Please Print All Information Property Owner's Name Parcel# i``i��l ,(�. i `�t� c;�6lcs//--c7,2 - /8i -.3 Property Owner's Mailing Address Property Location 4:'a1/ ( -'(, !r r- k C•• /■ / Govt.Lot City,State Zip Code Phone Number /, /4, Section (5-/--'—'7 i 4..ii , G✓% J Y l / 0Y 22'j '-17 t T N R (ciEorW) IA_/ II.Type of Building(check all that apply) Lot# 1 or 2 Family Dwelling—Number of Bedrooms 3 ,7 7 Subdivision Name ❑Public/Commercial—Describe Use Block# Pie 3-`t Hl- l'/7 /ici7 4 t" ❑ City of ❑ State Owned—Describe Use [ Village of CSM Number ❑ Town of l 4 — / itry1 III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ / A. ❑ New System ❑ Replacement System El Treatment/Holding Tank Replacement Only + "Other Modification to Existing System(explain) (.E C ..izil4e cA,r ,z B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV.Type of POWTS System/Component/Device: (Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation Rate(gpdsf) VI.Tank Info Capacity in Gallons Total #of °' ° C.)Manufacturer w o U Gallons Units B o ; New Tanks Existing Tanks a. U i73 . w V 0. Septic or Holding Tank ❑ ❑ ❑ ❑ ❑ Dosing Chamber ❑ ❑ 0 0 0 VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Address(Street,City,State,Zip Code) VIII.County/Department Use Only ❑ Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial $ IX.Conditions of Approval/Reasons for Disapproval 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 SBD-6398(R03/14)