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Attach to complete pians for the system and submit to the County only on paper not less than 8 1/2 x l l inchea%MN t II T WUNTY <br />ZONING <br />SBD -6398 (R03/14) <br />County <br />Industry Services Division <br />F' 8 <br />i-� <br />1400 E Washington Ave <br />P.O. Box 7162 <br />San' P Number to be filled in by Co.) <br />�} $ <br />Madison, WI 53707-7162 <br />(Q77 <br />` f IUv�ti <br />Sanitary Permit Application <br />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 <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m , Stats. <br />/ , <br />I. Application Information — Please Print All Information <br />Z '� 20 <br />i <br />Property Owner's Name <br />Parcel # <br />Ral /11 <br />Property Owner's Mailing Address _ <br />Property Location <br />o! Z 3 3 gyu ftaec <br />Govt. Lot <br />SLC '1.,56%, Section <br />City, State 4 <br />Zip Code <br />Phone Number <br />f <br />(crE r <br />N > R1� e) <br />T�� <br />IL Type of Building (check all that apply) <br />Lot # <br />_ <br />Subdivision Name <br />[ 1 or 2 Family Dwelling — Number of Bedrooms :3 <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />❑Village of <br />CSM Number <br />Town of <br />III. T <br />e of Permit: Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />i Replacement System <br />Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV. <br />Type of POWTS System/Component/Device: Check all that a ply) <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. DispersaVfreatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />Rate{gpdsf) <br />�_- <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # of Manufacturer m v° <br />Gallons Units <br />New Tanks Existing Tanks <br />n U y A. <br />Septic <br />Septic or Holding Tank <br />-Z <br />} tel/ ❑ (l ❑ <br />Dosing Chamber <br />❑ ❑ ❑ ❑ ❑ <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" ature PRS Number Business Phone Num r <br />V rc MP/M2 <br />7) <br />Plumber's Address (Street, City, State, Zip Code) <br />i C p <br />VIII. Coun /De artment Use Only <br />proved <br />r <br />Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Sign <br />'�Z�Zr= <br />❑ Owner Given Reason for Denial <br />$ 3 7� `� <br />�' <br />4nln'ar= r--'-, <br />IX. Conditions of Approval/Reasons for Disapproval <br />Ifl;re is iIN Vew % le ay? 01-,•r Je1-7�' v 9S_8'- <br />OCT 16 2017 <br />Attach to complete pians for the system and submit to the County only on paper not less than 8 1/2 x l l inchea%MN t II T WUNTY <br />ZONING <br />SBD -6398 (R03/14) <br />