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County <br /> Industry Services Division /3urnee <br /> r3 M7 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ', P.O. Box 7162 <br /> 6DOIa -�'t % Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Cam 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),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# y_J <br /> Ddn f✓a(�QtlatnJr✓ 07 o3G � ' M D43000 <br /> Property Owner's Mailing Address Property Location <br /> $.5-70 W. A f J L�Gi7,/ Govt.Lot 3 <br /> City,State Zip Code Phone Number y, y,, Section PY <br /> k/ ,,6Sfr✓ `o/7 ctretcone <br /> T tf0 <br /> II.Type of Building(check all that apply) Lot# N; <br /> Ior2 Family Dwelling—Number ofBedrooms d Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CStvl Number El Village of <br /> El State Owned—Describe Use ,-y UPIt a to <br /> t� Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System <br /> Replacement System ElTreatmentlHolding 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 /> Non-Pres4i d 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(st) Dispersal Area Proposed(st) System Elevation <br /> 3vD 7 9 4r3o� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> a U H co u v d <br /> Septic or Holding Tank 7-Ic-a 7_4_0 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,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 /> iC, !Yv /C,, , s /� /7 oi�ISBs'/ 7/f 8(�6- y/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 7760 /9.4 X _ZS tt, e,6.s7'-r.- wy �5'PS7 <br /> VIII.Court. [Department Use Onl <br /> Approved ❑ Disapproved Permit Fee Date Issued Is uing Agent Signature <br /> ❑ Owner Given Reason for Denial <br /> $375 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> p <br /> Sy '�rn C_ah Y�o� ,c) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 UZ.c 11 inches in size <br /> SBD-6398(R0313) <br />