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County <br /> Industry Services Division Bu r <br /> ® 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> $ ) P.O. Box 7162 <br /> s � Madison, WI 53707-7162MET <br /> J� O <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �s nod n'i <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# e <br /> /� 0�-04.1-1'? 8 od/a.tb <br /> Dt%n De Ye <br /> Property Owner's Mailing Address Property Location <br /> Fly 3 „oP A" e R/.1. Govt.Lot a <br /> City,State Zip Code Phone Number y,, '/., Section -7q <br /> CGfw+b.^fd c IV41 SSOa8 T 38 N' R (circle <br /> H.Type of Bu ding(check all that apply) Lot# <br /> ® Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms y <br /> Block# <br /> ❑PubliciCornrnercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> El State Owned-Describe Use V A� n <br /> :O.l � Town of Weed RI v'e✓ <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ®New System ❑ Replacement System ❑Treatment'Hotcimg Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> [V.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized tri-Ground ❑ .At-Grade ❑ Mound>24 in.of suitable soil 0 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(st) Dispersal Area Proposed(st) System Elevation <br /> 6, /. a 6 .90 1p ea <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units v "' <br /> 3 <br /> U H <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank <br /> Dosing Chamber GHQ gQ(7 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> /�/c/r I�o /min S <br /> Plumber's Address(Stfuet,City,State,Zip Code) <br /> oJ, 776o f 3S <br /> Vill.County/Department Use Only <br /> Approved ❑ Disapproved Permi-ttFere Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ 3 !`Z � &C, <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 S I/E s It inches in size <br /> SBD-6398(80313) <br />