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County <br /> "T = Safety and Buildings Division ^/ <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanit Permit timber(to be filled in by Co.) <br /> ASPS til Madison,WI537 0 7-7 1 62n <br /> Sanitary Permit Application State TransactionNtunbcr <br /> In accordance with SPS 383.21(2),Wis,Adm.Code,submission ofthis 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.I5.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name ,,_ t Parcel# <br /> -A ^ �a(7/�+1 07-0+/? - rl8tla 0 -o00-0 <br /> Property Owner's Mailing Address Property Location <br /> tY379 Ue yG U t-j:,� /o 7 Gort.L%)t <br /> City, <br /> yStt State ��/J�/ Zip Code Phone Number -/_Lh.L/�IA Section 2 <br /> //[QUINT ////v O�L �' circleonc <br /> 11.Type of Building(check all that apply) Lot# T 3g N; R E or� <br /> ❑ I or Z Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> Town of i <br /> 111.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Change of Plumber Lest Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POtiVTS System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Dl -folding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design F,llowt�(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(so System Elevation <br /> Vt.Tank Info Capacity in Total #of Manufactmcr <br /> Gallons Gallons Units 2 o Tr u <br /> New Tanks Existing Tanis �= c <br /> Uy y Y <br /> O 4 L v' tu Q r tJ l% 7m Li, t7 C. <br /> Septic or Holding Tank 2 Coe •J�s- <br /> 1 v <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) 11 Plumber' gnaturc M©PiMPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 7ZZC) -;r4H "M/,1 Acj <br /> VM.County/Department Use Only a <br /> Approved I Cl Disapproved Permit Flee 8 Date Issued `7 Issuing Agent Si <br /> ❑Owner Given Reason for Denial S ` r ��- / / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nD ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR x la size <br /> P <br /> t.i <br /> SBD-6398(R.11/I I) <br />