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1.'14nart0,1vil, County <br /> Industry Services Division �u M r+ <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled m by Co.) <br /> ° g D P.O. Box 7162 �o �q <br /> , j <br /> Madison,WI 53707-7162 lJ _I <br /> Sanitary Permit Application StatcTransactiort Number <br /> In accordance with SPS 393.21(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(I)(m),Stats. 7s-[ 7 <br /> L Application Information-Please Print All Information (� <br /> Property Owner's Name Parcel p yf, A' 33 s-eS <br /> C}eat-d- <br /> ��µ� SGh a,ar-tz —oD.T —61SDOO <br /> Property Owner's Mailing Address Property Location <br /> d b76 In i Sa!'d 1>14t 4 eC wl�` Govt.Lot 3 <br /> City,State Zip Code Phone Number y,, Section 33 <br /> 106 Af le W/d It ✓�. / b - ,raj O 7 4(,S- <br /> (circle one) <br /> N; R <br /> It.Type f Building(check all that apply) Lot# T_�� _/o E of:�V <br /> ® I or 2 Family Dwelling-Number of Bedrooms `� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of_ <br /> Town of .Swlfr <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ Treahnem/Holding Tank Replacement Only ❑ Other Modification to Existing S (explain) <br /> stem(ex <br /> 11 New System �Replacement System y p <br /> B. ❑ Permit Renewal ❑ Permit RevisionList Previous Permit Number and Date Issued <br /> ❑ Change of Plumber 11 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com ponent/Device: (Check all that apply) <br /> 4 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 im 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> Zif- . 7 G 43 (0sr/ I ".o a 98• a <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o '$ <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank ,BO <br /> Z�zl lee 20 <br /> Dosing Chamber 4B0 (0 Of/ <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 /> Ae 17a /n f j f Tt pt yitr> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7 G <br /> VIII.County/Department Use Only <br /> Approved El Disapproved <br /> Permit Fee Date Issued Issuing Age Si a[ur <br /> ElOwner Given Reason for Denial $3 7th. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> mew /V Zl �/�;ti7�a;sv S�l�,t�a <J�'s (ger SPS 3 <br /> Attach to complete plans for the system and submit to the Counry only ou paper not less than S u2 x 11 inches in sin <br /> SBD-6398(R0313) <br />