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two b, Industry Services Division County 11� <br /> yt. 1400 E Washington Ave ( T <br /> it �:` P.O.Box 7162 Sanitary Peewit N> (to be filed in by Co.) <br /> r �1j !r; Madison,WI53707 7162 N_ _1$LI <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),1Vit.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application faros for statoowned PO WTS are submitted to Project Address(if different than mallitrg address) <br /> the Department of Safety and Professional Services.Personal lnfmttmtion you provide may be used far secondary <br /> uses in accordance with the Privacy Law,s.15.04(1)(m Stets. ' <br /> I. Application Information-Please Print Ali Information <br /> Property Owner's Name Parcel# <br /> Fac- <br /> Property Owner's Mailing Address Property Ltrratiaa <br /> Z Govt.Lot t <br /> City,State ZIP Code Phase Number N W II.,�_/YSection <br /> T N, R__11L�one) <br /> che ^ <br /> H.Type of Bull ( ck all that apply) Lot# <br /> a[or 2 Family Dwelling—Number of Bedrooms 6 Subdrvision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Z ZO FTmm <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 1P Replacement tem ❑TreatmenYHoldin Tank Replacement Only ❑Other Modification to Exist stem(explain) <br /> eP � g ep Y �S}' ( P ) <br /> B. ❑Change ofPhtmber Q Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑Permit Renewal Q Pamir Re+tision 2 2 5 10 ltr <br /> Before Expiration Owner I to-b I <br /> IV,Type of POWTS System/Component/Device. Check all that apply) <br /> Ql Non-Pressurized la-Ground ❑Pressurized In-Ground 0 At-Girade ❑Mound>_24 in.ofmitable soil ❑Mound<24 in.of suitable soil <br /> UL Hording Tank ❑Other Dispersal Component(explain) [3 Ptetteatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed Est) System Elevation <br /> 100 1 •119" 1 l /8W " 1717 9TO 9zo <br /> VI.Tank Info Capacity in Total €of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Exist' Tanks v <br /> zg9 <br /> 1 I in m a <br /> Septic or Holding Tank 5t t ial , Z <br /> Daft Chamber <br /> VII.Responsibility Statement-I.the undersigned,ass um responsibility for nitafl t of the POWFS shown on the attached plans. <br /> Plu cr's Name(Print Plumber's MP/MPRS Number 7 Business Phone Number <br /> 10 <br /> Plumb►r's Address(Street,City.State,Zip Code) <br /> 01fr ut- 5�189 <br /> VIlL Coun !Devartment Use Only <br /> QApprovcd ❑Disapproved Pemtit Fee Date lsatred issrrirtg <br /> ❑Owner Given Reason for Denial 1s37,5 <br /> 91151/�3 <br /> I X.Condl ons of f;ppro ns for Dlaapproyal <br /> MM a" Se a S MAVAfs D <br /> Uar;'S �,�IS �� � i�cS O� � <br /> 5 ® I <br /> - 23 <br /> Attach to tomplete prays tar the slstem and submit to the Ccatrtry an$an paper net tags than H i fServic:QDepartment <br /> ounty <br /> Land <br /> �,, � 5°jt <br /> SBD-6398(R.08114) �.-� (au�( <br />