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ON COMPUTER/SCANNED <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 x'""E- <br />TT <br />- T COUNTY <br />ZONING <br />SBD -6398 (R. 11/1 l) <br />Safety Buildings Division <br />County 47 <br />and <br />u(tvelt <br />Sanitary Permit Number (to be filled in by Co.) <br />201 W. Washington Ave., P.O. BOX 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Vis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Late, s. 15.04(t)(m), Stats. <br />1. Application Information - Please Print All Information <br />Property Owner's Name �j <br />Parcel n <br />,�y� <br />/�l �roov <br />//[ <br />loft <br />Property Owner's Mailing- Address <br />Property Location <br />Z6151 V4 NNC T Ag-_ <br />Govt. Lot q, <br />y, /,, Section / <br />City, St to <br />Zip Code <br />Phone Number <br />ku(v�@ <br />t <br />tU <br />/, G C <br />�✓'JKI��TZt� —T-40 <br />,J`' (circle on <br />N: R16Eo \V <br />II. Type of Building (check all that apply) <br />Lot R <br />Subdivision Name/ <br />I or 2 Family Dwelling -Number of Bedrooms Z <br />Z <br />Block <br />fP G� A0 <br />❑Public/Commercial -Describe Use <br />❑ City of <br />❑ State Owned -Describe Use <br />❑ Village of /I _ <br />15t64tk- 4 W <br />CSM Number <br />U 6 P5 <br />Town of <br />Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />ElNew System <br />�rRcplacement System <br />❑ Treatment/Holding Tank Replacement Only <br />Other Modification cation to Existing- System (explain) <br />B <br />11Pztmit Renewal <br />❑Permit Revision <br />❑Change of Plumber <br />ElPermit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />-- <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />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) I <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sO <br />System Elevation <br />06 I <br />Iyj <br />ti'2 <br />1 z, o <br />VI. Tank Info <br />Capacity in <br />Total r of <br />Manufacturer <br />Gallons <br />Gallons Units <br />v c y <br />New Tank; Existing <br />Tanks <br />o u <br />X. U mn -v; rn i_ 0 a <br />Septic or Holding Tank <br />�.A� <br />QV <br />co <br />eco <br />w <br />Dosing Chamber <br />VII. Responsibility Statement- 1. the undersigned, assume responsibility for installation of the POIVTS shown on the attached plans. <br />Plunt s Name (Print) <br />Plumber' ianaturc <br />MPrMPRS Number <br />Business Phone Number <br />�1!2 0 <br />i5- BGG -o _0 z. <br />Plumber's Address (Street, City, State, Zip Code)�F_'2r�� <br />q <br />5119 <br />/J,-, <br />VIII. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Penttit Fee <br />0 <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />S 715 <br />IX. Conditions of Approval/Reasons for Disapproval <br />OCT 13 2017 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 x'""E- <br />TT <br />- T COUNTY <br />ZONING <br />SBD -6398 (R. 11/1 l) <br />