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;uppAPT111pA,T Countty. <br /> c/I Safety and Buildings Division u r 2Z e ff <br /> Irk 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' Madison,WI 53707-7162 <br /> OpfP`i�' �5i a WL, <br /> Sanitary Permit Application State/ U Transaction Number <br /> In ccordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental l- i' U <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Servies. Personal information you provide may be used <br /> for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m), ts. <br /> 1. Application Information-Please Print All Information �"5 <br /> Proper[Z Owner's Name Parcel# �0 <br /> C'(x co/ /1 Coe ! —03 71,— a-3 /61 Z 6 y <br /> Property Owner's Ma iling�A^dd0 <br /> Address / n ) �j Property Location )_a�— Qja� <br /> 1106 J /1are I� C �r� Govt. Lot <br /> CityL.�lakte Zip Code Phone Number A&I 'A, .i e 14,Section 26 <br /> �'edE f.C LtJ rw S`>'�3 t/ //,,7 s Z �'t1 7 7� (circle one) <br /> II. Type of Building(check all that apply) Lot# T J N; R��E o� <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> g3 <br /> Block# - iG3_&-b3_3 <br /> D Public/Commercial-Describe Use D City of <br /> D State Owned-Describe Use CSM Number D Village of 7� <br /> 13eTown of %Y,4c�/& /Q x V- <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. D New System X Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. 001 Permit Renewal D Permit Revision D Change of D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound > 24 in.of suitable soil D Mound < 24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) .,traT /e4 n D Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal AreaRequired(sf) Dispersal Area Proposed(sf) System Elevation / p <br /> 300 . 7/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units " o 'er u <br /> New Tanks Existing Tanks o <br /> aE U in ti ii U a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume res ons"ity for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Prin ) Plum Sig r MP/MPRS Number Business Phone Number <br /> ��/ten i336ss /s�s3-zs� <br /> Plumber's Address(Street , City, State, Zip Code) <br /> 372 i�� sr �re��•`� �� ���3 7 <br /> VIII. County/Department Use Only <br /> roved D Disapproved Permit Fee Date Issued Issuing Nent Signature <br /> 1�, _�� <br /> El Owner Given Reason for Denial $ 6D. W <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 s 112 x 11 inches in she <br /> SBD-6398 (R. 11/11) <br />