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County <br /> Industry Services Division f�w <br /> �� .•n)' : z: ;, p. 1400 E Washington Ave Sanita Permit Number,� �. ,,:•., �+# ry (to be tilled in by Co.) <br /> z�> <br /> P.O. Box 7162 t 640628 <br /> Madison,WI 53707-7162 <br /> �ti y I <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 PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary 2�$57 <br /> urposes m accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. A lication Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> �a�✓rcnc� ,c3c�ctill-cH c7-m3�1���11--6-/,?38� <br /> vY- b <br /> Property Owner's Mailing Address Property Location <br /> 6/31.a t-,J. Xrr w 11 ,!Ao( Rof ' Govt.Lot <br /> City,State Zip Code Phone Number / _ Y4, Section / <br /> Pt-/&,Y n.7 /V I (circle one <br /> II.Type of Building(check all that apply) Lot# <br /> T_,�,N; R��E or rJ <br /> 1 or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use El city of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> Town of <br /> lii.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.. 'o.of POW'I'S.S stem/Corn onenUDevice: (Check all that apply) <br /> -Non ke�ni6d In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ FfdI:Ig k ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> WD s e I/Treatment Area Information: <br /> Desig Tlft(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w [ u <br /> c U cn y <br /> Septic or Holding lank JO�O <br /> Dosing Chamber_ 1 t <br /> ViI.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street City,State,Zip Code) <br /> 3s !�.e 6 <br /> VIII.Conn <br /> /De artment Use Only <br /> ❑Approved ❑ Disapproved Permit Fee Date.Issued Is ge ignatur <br /> ❑Owner Given Reason for Denial <br /> IY.Conditions of Approval/Reasons for Disapproval _ <br /> 0767! <br /> J1 75 Qa <br /> S E P 10 202,1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In.x it nchas in size Sumett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />