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County <br /> �f:;• Industry Services Division <br /> != =:.y' '- �.+ 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,�i:.:+ «•;:: P.O. Box 7162 <br /> Madison, WI 53707-7162 <br /> _y <br /> ' - <br /> State Tran action Number <br /> Sanitary Permit Application In accordance accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Form to the appropriate govermnental 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 7 y 3 O <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information Parcel# y�_tb.;S•S�s vm'4 <br /> Property Owner's Name <br /> ?goo <br /> Dea h Pe4y-v'y,h <br /> Property Location <br /> Property Owner's Mailing Address <br /> b A161,'fl, 1'901 .Sf Govt.Lot <br /> City,State Zip Code Phone Number %, '/., Section .�� <br /> �r- (circle one <br /> (:f Ica �k 1 � `J�b�� i? T y19 N; R /b E 01 <br /> II.Type of Building(check all that apply) Lot# <br /> 3 �a Subdivision Name <br /> t or 2 Family Dwelling-Number of Bedrooms D <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number El Village of <br /> El State Owned-Describe Use Town of Oa AC off' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A.. El New System ❑Treatment/Holding Tank Re lacement Only ❑ Other Nloditication to Existing System(explain) <br /> Replacement System Rep <br /> la <br /> ❑ permit Renewal ❑Permit Revision ❑Chan�ofPlurn�ber []Permit Transfer to New <br /> List Previous Permit�Number�Datessued <br /> Before Expiration wner <br /> IV.C: e of POWTSIS stem/Com onent/Device: (Check all that apply) <br /> '---d ❑ Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑Nau P�essunzed In-Ground El In-Ground ❑ At-Grade _ <br /> ❑ Ifol"—Tank El other Dispersal Component(explain) El Pretreatment Device(explain) <br /> V Dis ersnl/Treatment Area Information: Dispersal Area—Proposed st System Elevation <br /> DesfgnTI&(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) pO Q' <br /> "Tso /. o Aso Yso <br /> VI.Tank Info Capacity in Total #of Manufacturer Y o <br /> Gallons Units o ° ° <br /> Gallons <br /> Existing Tanks Z <br /> New Tanks a U cn N � <br /> Septic or Holding Tank /.(OO /L BO <br /> Dosing Chamber_ 7S'O 7" <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POIVVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur NIP/NIPRS Number Business Phone Number <br /> /2► atits�lf'/ 7�.5= �6G' "�'/S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 771,o <br /> VIII.Countyment Use OnlD <br /> Permit Fee Date Issued Issuing Agent Signatur _ <br /> Approved ❑ Disapproved <br /> $ <br /> ElOwner Given Reason for Denial <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 8 112 x 11 inches in size <br /> SRO-6398(R0311) <br />