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i�yrri!y County/� <br /> f Safety and Buildings Division [) e r/1-e <br /> 201 W.Washington Ave.,P.O. Box 7162 Sanitary PermitNumber(to be filled in by Co) <br /> �.� P. � <br /> S5 <br /> Fl Madison,WI 53707-7162 5$ Q z <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 kview <br /> is required prior to obtaining a sanitary permit. Notes Application forms for state-awned 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(l m Stats. -7 e, <br /> 1. Application Information—Please Print All Information J <br /> Property Owner's Name � Partial A <br /> 141o, AL 07 0aS z yo*,75-a 0/ 0do a/ 000 <br /> Property <br /> 'Owner's Mailing Address Property Location <br /> / { GJ Govt.Lot <br /> City,State Zip Code Phone Number <br /> '/, Section <br /> 00,7 t-' !!(circle one <br /> T �T or <br /> I .Type of Boihiing(check all that apply) Lot k N; R E <br /> I or 2 Family Dwelling-Number of Bedroom / Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 1) C I-VY 19'lownof Sco <br /> III.Type of Permit: (Check only toe box on line A. Complete line B if applicable) - n)- <br /> A, ❑News stem P(R Iacement System ) <br /> System ep y ❑TreatmenUHolding Tank Replacement Only El Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer m New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S sten/Com oent/Device: Check all that apply) <br /> [KNOn-Pressurized In-Ground D Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) i]Pretreatment Device(explain) <br /> V.Disperaalfirreatment Area Information: <br /> Design Flow(spill Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3P0 . 7 -/-19 . 5-7 s790� 489. Do <br /> VI.Tank Info Capacity in Total p of Manufacturer <br /> Gallons Gallons Units o'� <br /> Nm Tanks Existing Tanks a c y yy g <br /> Y U in <br /> Septic or Holding TmkSbin //�� / //4 Gu <br /> Dosing Cl mibee G // <br /> VIL Responsibility Statement- 1,We undersigned,aswme responsibility for installation of the POWTS shown on We attached plans. <br /> Plumber's Name(Print) I Plumber's Signature MP/MPRS Number Business Phone Number <br /> PI is Address(Street,City,State,Zip Code) <br /> VIII Couo /De rtment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued IssuingAgmture <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attaeh b caropkh plum for the sysiem and submit to the County only m paper not teas own 9 in 11®cbes baiter <br /> SBD-6398(R. l l/11) <br />