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`ip--;„p<<r\ Industry Services Division County n`� <br /> r 1400 E Washington Ave Dit tai 1 <br /> ' P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Iii•7 ' $ !.. Madison,WI 53707-7162 <br /> .: r i u 1 ( C C -7 22 <br /> "-:-/J4 ,7,:,1',7?-- <br /> pr State Transaction Number <br /> Sanitary Permit Application <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stats. I<UQ��1vlg 1�1�}V� <br /> I. Application Information-Please Print All Information Parcel# <br /> Property Owner's Name <br /> �r� c7-110- 352-X050+9 <br /> Nevi Q£n2 & tGtrL'(1 `-2`-`"o Property <br /> Location <br /> Property Owner's Mailing Address <br /> zl 3 Ray Cf. � Govt.Lot <br /> City, Zil ede Phone Number .E /, 1,1\n1 '/s, Section -5 <br /> �� (circle one) <br /> M Vl te-tt.,V\, tiJ t 53_ 9-- T .7 N; R t0(circle <br /> on <br /> H.Type of Building(check all that a. Lot# <br /> I ly 4 I Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Be. .o■s ”� fop si Nam <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of, <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use V Town of glC G`n-u <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. VtNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Owner <br /> Before Expiration <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) <br /> ❑Pretreatment Device(explain)• <br /> V.Dispersal/Treatment Area Information: Dispersal Area Proposed(sf) System Elevation <br /> I Dis <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) A3,5' <br /> �`�© .4 I ��Capacity in Total #of Manufacturer V <br /> VI.Tank Info o <br /> Gallons Gallons Units U �, <br /> V g 2, 2 « p A R <br /> New Tanks Existing Tanks a U iii to a.v a' <br /> Septic orFleidWg Tank i 2 oo 12c I A.E/\f i < <br /> Dosing Chamber 7 - 1 M ' <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS sPh�RS Numb attr ached Business Phone Number <br /> Plumber's Name(Print) Plumber's Signature ".......(. <br /> 5 e3(-2I03 <br /> Plumber's Address(Street,City,State,Zip Codc) ( ' <br /> G53 Cex,vv*— #-L-f, (L WGu,t.iutkee,‘A 535D-7 <br /> VIII.County/Department Use Only Permit Fee Date Issued Issuin Agra igna e '■1-"Y"v <br /> KApproved ❑Disapproved $ <br /> ❑Owner Given Reason for Denial <br /> 'i 31 q-11-2cre <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 /> SCANNED <br /> SBD-6398(R.08/14) <br />