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NlVcv, Industry Services Division County 4822 Madison Yards Way lid—C� <br /> a� I � Madison,WI 53705 S itary Permit Num er(to be filled in by Co.) <br /> P.O.Box 7302 �2t�,�� / <br /> Madison,WI 5302 G <br /> Sanitary Permit Application State Transaction Number w 7 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ��� �T ,� �� <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> mo -t33? -yl IS-13 <br /> Property Owner's Mailing Address Property Location T.X `D 2,13 S <br /> �cT Govt.Lots eF <br /> 'City,State (� Zip Code Phone Number1�/ N <br /> !� 3Z� — ,.C.(YOS ` 1/.,scC '/., Section <br /> 1I.Type of Building(check all that apply) Lot# T Y j�N R E o <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name rA <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> CcTown of Qt } _ <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> New System ❑ Replacement System ❑ Other Modification to Lxisting System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank An-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 5c) .1 ley 3 -79 9 b.3 9 y• 7 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units c b <br /> New Tanks Existing Tanks w c <br /> a U V� y cn w C7 0. <br /> Septic orHolding Tank 1X <br /> Dosing Chamber ll <br /> V.Responsibility Statement- I,the undersigned,assume responsibility f installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's Signature MP/M}'RS Number Business Phone Number <br /> .�/ V/S R4�"� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> yZ4-Z$ kAVANAQQ1 AD, C40I&I 1AJ1 sye Lil <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Dale <br /> Issued <br /> Issuing Agent Signatu c <br /> ❑Owner Given Reason for Denial $��� 6124I2aq <br /> Conditions of Approval/Reasons for Disapproval eulf <br /> w+ au k4" <br /> a� cun oid 14a-k r c�✓��f5 <br /> JUN 112121 <br /> Burn Countg <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/ x 11 i iett <br /> r Department <br /> SBD-6398(R.02/22) <br />