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`! Safety and Buildings Division <br />County <br />B u (xy 15 i <br />Sanitary Permit Number (to be filled in by Co.) <br />•~'" 201 W. Washington Ave., P.O. Box 7162 <br />,$F 1'± Madison, WI 53707-7162 <br />$_ <br />Sanitary Permit Application <br />State Transaction Number <br />in accordance with SPS 383.21(2), W is. Adm. Code, submission of this form to the appropriate governmental unit <br />Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. <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 Stats_ <br />a i to it ii b, it) L <br />Parcel # <br />I. Application Information -Please Print All Information <br />Property Owner's Nage <br />Property Owner's Mailing Address <br />Property Location <br />1 L� <br />Govt. Lot j <br />/4, /4, Section / <br />City, State <br />Zip Code <br />Phone Number <br />_�/ <br />t �LAIIt t W } <br />5 q 701 <br />j circle one <br />-1 0 N; R�EofW <br />1iV <br />Lot # <br />T <br />H. Type of Building (check all that apply) � <br />Subdivision Name <br />� <br />lam' 2 Family Dwelling - Number of Bedrooms <br />Block # <br />�E''..� <br />laity of _ <br />rQr a <br />ublic/Commercial - Describe Use <br />�illage of <br />F„ <br />tate Owned -Describe Use <br />CSM Number 2.41 b <br />� <br />%own of -co-AT <br />�1 <br />I r � �r <br />III. Type of Permit: (Check only one box online A. Complete line B if applicable) <br />w System I "'Replacement System 1`, reatment/Holding Tank Replacement Only �� her Modification to Existing System (explain) <br />B. Hermit Renewal <br />En ermit Revision <br />1 ^,mhange of Plumber <br />e <br />U!'%lermit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. T e of POU S stem/Co onent/Device: Check all that apply) <br />k.. E; Ey <br />�ound <br />on -Pressurized in -Ground essurized In nr. t -Grade > 24 in. of suitable soil ' ound < 24 in. of suitable soil <br />[-� e:; <br />E,�� olding Tank 1 �+nrher Dispersal Component (explain) I : retreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Desi n Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation <br />01 <br />VI. Tank Info <br />Capacity in _ <br />Gallons <br />Total <br />Gallons <br /># of <br />Units <br />Manufacturer v <br />r, U <br />c °3 <br />H <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />1 <br />Dosing Chamber <br />o <br />001 <br />VII. Responsibility Statement- I, the undersigned, assume pvpoqsibiloy for ustallation of the POW TS own on the attached plans. <br />be Name Name (Pr Plumber's S' atur IP PRS Number Business PhoneNumber <br />AJ tJ it-�-�� L"I e '� c <br />Plumber's Address (Street, City, State, Zip Code) <br />1J S%) -I lr ' Jo h U -Z7 6N SO 1 ...r <br />County /De artment Use Only <br />-VIII. <br />pp roved <br />e� isa roved <br />°° PP <br />Permit Fee <br />Date Issued <br />Issuing Agent Signator <br />E"M <br />$ 37s eo <br />/1-2/ -17 <br />wner Given Reason for Denial <br />LY. Conditions of Approval/Reasons for Disapproval <br />Attach to complete plans Ior SRC system anu suu11111 w um �ty uu.� u., pays. ,,.,. ........,., •— - <br />SBD -6398 (R. 11/11) <br />