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County <br /> Safety and Buildings Division <br /> 0S = 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P Madison,WI 53707-7162 �6—q4 -f -3 <br /> Sanitary Permit Application SSttaJteTTransac"mt�Njn'nbe` <br /> In accordance with SPS 38321(2),W is.Adm Code,submission of this form to the appropriate governmental unit c / oC <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. 1 m Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Own 's Mailing Address Property Location <br /> O(J Govt.Lot <br /> ICity, <br /> State Zip Code Phone Number /, 'A, Secti0n.2,5+- <br /> circle one <br /> ll/ VVI T N; R E o <br /> II.Type of Bnildmg(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Cmamemial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of ,yJ _ <br /> G ///own of IVa A-' <br /> III.Type of Permit.- (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System y � ep ys ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Last Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of PORTS System/Componeat(Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ry Mmm1>24 in.of suitable soil ❑Mound<24m.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain)_ ______ ❑Pretreatment Device(explain) <br /> V.DIS <br /> er.5% eatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> O. o S O O <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks <br /> 0 <br /> /000 <br /> / U v, tA <br /> tA in i,, c7 R. <br /> Septic or Holding Tank <br /> Dosing Chamber Q 0 <br /> r <br /> VII.Responsibility Statement-1,the undersigned,assume respemsibillty for installation of the POWTS shown on the attached plans. <br /> Phmtbet's Name(Print) Pfiu bZignaturc MP/MPRS Number Business Phone Number <br /> ' aS-o3 lis- -3 <br /> Plumber's A7darm( treet,City,State,Z- Code) <br /> S w <br /> II.Coun /De artment U Onl <br /> Approved I ❑Disapproved Permit Fee Date Issued // Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial <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 leas than g W s 11 inches in size <br /> SBD-6398(R. I1/11) <br />