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Co <br /> / . Safety and Buildings Division <br /> i A. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <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 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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04 1 m),Stais. �/�/� L <br /> I. Application Information-Please Print All Information <br /> Property Oyster's Name Parcel# <br /> CC�7-CYZ-0 /r-ZZ-5- <br /> �1# s� 3Y1 IS <br /> Property Owner' railing Address Property Location <br /> U A/e S / Govt.Lot <br /> City, tate Zip Code Phone Number , ZZ���� `/- /y /., Section <br /> �G�.� l� �'��'_ L���� T_i__N; R _I� leo one) <br /> 1-1,..Type of Building(check all thatapply) Lot# t <br /> NJ 1 or 2 Family Dwelling-Number of Bedrooms 7g D Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of_ <br /> ❑'`-town of T ffCin <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A' ew System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e of POWTS System/Component/Device: Check all that apply) <br /> on-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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 Systew El'ation <br /> 5 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> Now Tanks Existing Tanks v u <br /> a0 <br /> U in vi V) is.0 Ci. <br /> Septic or Holding Tank <br /> Dosing Chamber t� <br /> VII.Responsibility Statement-I,the undersigned,as ume reflp4sibility for installation of the POWTS shown on the attached plans. <br /> P mber's Name( nt) Plum �s Si MP/MPRS Number Business Phone Number <br /> 77� 'y3 �/S- 9�?l -111X6 <br /> umn 's Address(Street City,State,Zip Coders) <br /> VIII.County/Department Use Only <br /> ,-Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial Z z,�, <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 a in size <br /> MAY 11 N21 <br /> SBD-6398(R. 11/11) <br /> �v�ees Oap�trlv�eftt <br />