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Industry Services Division <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Madison, W1 53707-7162 <br />County <br />Sanitary Permit Number (to be filled in by Co.) <br />,� a64y <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 <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Laws 15.04 1 ml Stats 17939 <br />I. Application Information — Please Print All Information hf WV <br />�(- <br />Property Owner's Name Parcel # <br />Property Own&% Mailing Address <br />City, State ` Zip Code <br />( 1/V i ✓1 /l/I /�% r� <br />U. Type of Building (check all that apply) <br />I or 2 Family Dwelling - Number of Bedrooms <br />❑ Public/Commercial - Describe Use <br />❑ State Owned - Describe Use <br />'00i <br />Property Location (% 4 <br />Govt Lot <br />Phone Number �j '/a, Section L� <br />—� �'� <' / © q, (circle <br />T .0N R/� Ea W <br />Lot # <br />Block # <br />CSM �lupber <br />III. T e of Permit: Check onl one bog on line A. Complete line B if applicable) <br />A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only <br />Subdivision Name <br />❑ City of <br />❑ Village of <br />Town of ,A ; <br />❑ Other Modification to Existing System(explain) <br />B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued <br />Before Expiration Plumber Owner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) 1' <br />Non Pressurized In Ground ❑ Pressurized In -Ground ❑ At -Grade <br />❑ Holding Tank El Other Dispersal Component 13 Mound > in. of suitable soil C3 Mound < 24 in. of suitable soil <br />p (explain) Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Application Dispersal Area Required (sfl Dis <br />Rate(gpdsf) `('(� persal Area Proposed (sf) System Elevation <br />L4S© E7 l� <br />VI. Tank Info C aci �J' Z <br />ap ty in <br />Gallons <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume <br />Plumber's Name (Print) �Plumbe�'iq <br />Plumber's Address (Street, City, State, Zip Code) <br />W70 Z: Da / % �- L n L, <br />Total <br />Gallons <br /># of c <br />Units Manufacturer <br />U to y <br />� GL V <br />a <br />❑ ❑ <br />❑ <br />isibility for installation of the POVvTS shown on the attached plams. <br />MP/MPRS Number <br />Business Phone Number <br />' <br />e 10 i� <br />-7i, n-�zac <br />Z- c o mac/ S <br />Approved ❑ DisapprovedPermitt Fee D o Date Issued Issuing Agent Signature <br />❑ Owner Given Reason for Denial $ 3/ <br />LX. Conditions of Approval/Reasons for Disapproval <br />to complete plans for the system and submit to the County only on paper not leas than 8 v2 a 11 inches in <br />SBD -6398 (1103/14) <br />