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Industry Services Division County <br /> 1400 L Washington Ave �� , „ c?r <br /> J _' � ' P.O_Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> f Madison,WI 53707-7162 _6�3 <br /> 0 <br /> /0 <br /> Sanitary Permit Application State'FmnsactionNumber <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. ) cjs'9 �q 5/u, L <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> t,7-oaa- l 39-111-'3 s <br /> 1 �ii,nt3 Gr-0rN a/y000 <br /> Property Owner's Mailing Address Property Location <br /> 4 3 4 ( G re S 6,Y x4e Govt.Lot 3 <br /> City,State Zip Code Phone Number y, Y., Section 3 <br /> MX/ <br /> L r G✓wr f� 5 S B7l/ k3%- 3/S_ /� POrt (circle one <br /> II.Type of Building(check all that apply) Lot# T 3 cj N; R i4/ F o <br /> L3 I or 2 Family Dwelling-Number of Bedrooms 0), Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number (( El Village of <br /> \ <br /> 1/, I P, I C14 �Town of R'x <br /> III.Type of Permit: (Check only one box on line A. Complete line Bif applicable) <br /> A. New System ,�Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to ExistingSystem(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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 10 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.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(sf) System Elevation <br /> ate . "7 yJ s `13a <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � � U <br /> Neu Tanks Existing Tanks o 0 y a <br /> a U in v v: iL U a <br /> Septic or Holding Tank 1pG0 /000= WttjY✓ X <br /> Dosing Chamber <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/MPRS Number Business Phone Number <br /> ,21 / 1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Age ignature <br /> ElOwner Given Reason for Denial $ 37-15 Z11 <br /> IX.Conditions of ApprovaFReasons for Disapproval <br /> A-rei ,' aro( /odd AHAOA,"` rll,�d -C-o 414 <br /> �i <br /> Attach to complete plans for the system and submit to the County only on paper not less than s 12 x 11 inches In sin <br /> SBD-6398(R.08/14) <br />