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Co y <br /> Safety and Buildings Division ufgJGf <br /> Al` 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> :a ASPS ' rl Madison,WI 53707-7162 �J`q�/ <br /> ' - <br /> 10 1 <br /> Jt�- <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(t)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property O , er's Name Parcel# <br /> 44A0V 4-T co,-002—olzme <br /> Property Owner's Mailing <br /> Address Property Location <br /> Z NI NTS/ ev `/V Govt.Lot O- <br /> City,State Zip Code Phone Number y,, Section <br /> � 1 SyB�O 7is=Z6t-781 /� rcED <br /> 11. <br /> 4 <br /> T "(� N; Rr� <br /> 11.Type of Bu lding(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of /`��� <br /> *211e Q y/nzoq �,Town of 'Z.(71-T <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A.A. <br /> ❑ New System Treatment/Holding 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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> [Pon-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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed Is System Elevation <br /> •7y2 1 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o a v <br /> U <br /> New Tanks Existing Tanks u o :: 2 m a <br /> o.U rn y rn Lz U o. <br /> Septic or Holding Tank 4900 000 J- <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plroo, <br /> s Name(Print) Plum Signature MPiMPRS Number Business Phone Number <br /> 5 D Jew �� 85185 ?is-566 -oz oZ <br /> Plumber's Address(Street,City,State,Zip Code)) / G <br /> 27ZZo 1QA'!t";t: A;v (/1�P�b5�F)" l..l r 578 <br /> VIII.County/Department Use Only <br /> Approved 11Disapproved Permit Fee O Date Issued Issuing Agent Signatu <br /> El 11 <br /> Given Reason for Denial S /� <br /> IX.Conditions of Approvat(Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size <br /> SBD-6398(R. I I/11) <br />