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Industry Services Division County <br /> 1400 E Washington Ave gAr�tt` <br /> ®S P P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 <br /> ijki c21--3o 6406$v3 <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 Services.Personal information you provide may be used for secondary R796r 5 / /4,e e. <br /> purposes in accordance with the Privacy Law.s. 15.04(1)(m).Stats. /v�t�( ! /t /� <br /> I. Application Information-Please Print All Information I,Je45f r G✓. <br /> Property Owner's Na Parcel# <br /> d/)C(I-- y ill a�-aa—a-Ya-isr..u-5.os-aor- • <br /> Piopert)Owner's Ma in ddress REVISEDProperty Location <br /> 601e,l�lu Govt.Lot City.State Zip Code Phone Number 14. r/a. Section 2r <br /> l'i60Ir�/� ! Mw1/4I 55112 (FircleEe <br /> T �o N: R t) onorW <br /> IL Type of BuAding(check all that apply) li L ot# <br /> XI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# / <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> yr Town of TAcik r/j <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System $Replacement System 0 Treatment'Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of FOWLS System/Component/Device: (Check all that apply) <br /> CNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area equired(sf) Dispersal Area Proposed(sf) System Eles tion <br /> 600 ,7 9 J go' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s 2. _ u <br /> New Tanks Existing Tanks .3 c u . 2 41 <br /> i G in r v1 ii. C7 a <br /> Septic or Holding Tank x 1'1 o, / lA/kt SC p �/ <br /> Dosing Chamber X iSD / m ire/ mil" <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's tyame tin Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street.City, rate.ZipCc e) ^. <br /> r 7// o270r a 'uc / t�Ya ig <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> ❑Approved ❑ Disapproved $ <br /> ❑ Owner 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 U2 x 11 inches in size <br /> SBD-6398(R.08/14) REVISED <br />