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Industry Services Division County <br /> %,/ 1400E Washington Ave 1:4Y1P_. <br /> iii. B. P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> fig,�'_r +' Madison,WI 53707-7162 \\ / <br /> *_+±.;..s - 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 rr���ft <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. `. GAY Y�(e t 1 rat R . <br /> I. Application Information-Please Print All Information Parcel# <br /> Property Owner's Name <br /> Dale IS< Kily Lurmi chAe l 0111-,94A-X115-C.) <br /> Property Location <br /> Property Owner's Mailing Address <br /> Jl i 1 Ctv Govt.Lot <br /> 132 W■IS�� h, Section <br /> City,State � Zip Code Phone Number SE. '/•, r E <br /> (circle one) <br /> x,11 SC`il1 111 5370.3 T "7 N; R 1 1 E <br /> Lot# <br /> H.Type of Building(check all that apply) Loi Subdivision Name <br /> %i or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use 'Town of col-levy G"k6,e_, <br /> 1334S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' \7New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> rr List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> rNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Dispersal Area Proposed(sf) System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) pe <br /> Capacity in Total #of Manufacturer B <br /> VI.Tank Info •U <br /> Gallons Gallons Units w c u h <br /> New Tanks Existing Tanks n , <br /> 0 2 ,8 V rA <br /> a U in to to <br /> Septic or.idolding Tank ( `o ((PS{•) ( ' X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown o the attached plans. Phone Numbs <br /> Plumber's Name(Print) Plumber's Signature <br /> 1 reA,J <br /> W. Metrthd2 4t,-L- 60 A.9-0(145 83143)03 <br /> • •-----6‘--(11 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Cea13 C±/4-6)- K yJGlunzt.Kee, t,Jl 53097 <br /> VIII.County/Department Use Only Date Issued Issuing ens gnature <br /> Permit Fee /' <br /> Approved ❑Disapproved S ..1 i J ':>\ I��11—2.n/.8 C e <br /> ❑Owner Given Reason for Denial "i <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 8 112 x 11 Inches to size <br /> SCANNED <br /> SBD-6398(R.08/14) <br />