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17:. 1GIAICYT r�nl MTV <br />Safety Buildings Division <br />County <br />f - <br />and <br />C f <br />i <br />Y i ,SPS t j <br />201 W. Washington Ave., P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />5A N1 _ i <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 />Project Address (if different than trailing 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), Stats. <br />1. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />1' Z�iCi7 <br />-t+To— <br />Property Owner's Mailing Address <br />Property Location <br />7�" ro <br />Govt. Lot ?' <br />y, /l/ �1,� Section <br />City, State <br />Zip Code <br />Phone Number <br />OU l 'V ill <br />�L/e7JD <br />ircle one) <br />T �_N; R E oQ <br />11. Type of B ilding (check that <br />Lot # <br />all apply) <br />❑ 1 or 2 Family Dwelling — Number of Bedrooms 5 <br />Subdivision Name <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />of <br />CSM Number❑Village <br />�Townof ©QGIQn� <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />11 New System <br />❑ Replacement System <br />IKTreatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B • <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />"33 -7j r -,,,4, <br />IV. T <br />e of POWTS S stemlCom onent/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/Treat ent Area Information: <br />Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System El it <br />y5 D <br />6 10 <br />V1. Tank Info Capacity in Total # of Manufacturer <br />Gallons Gallons Units a <br />New Tanks Existing Tanks u o U Z <br />a U in rn L. U G <br />Septic or Holding Tank <br />t/� <br />/ <br />Dosing Chamber <br />VII. Responsibility Statement— I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plum s Name (Print) Plumber' =nature MP/MPRs Number Business Phone Number <br />5 <br />oii� ¢ ems- /'� -o-ao i <br />Plumber's Address (Street, City, State, Zip Code) <br />2 722o A�,l <br />�a,i,.J a" 5�9f <br />II. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />se <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />o <br />% <br />U <br />7 <br />a X e <br />IY. Condditions of Apprr/ovaVReasonns for Disapproval <br />P�Ga c,t r"e,- T e J T i ec/ I Rtie r��v <br />� <br />Attach to complete plans for the system and submit to the Counh only on paper not Less than 8 t2 11chW UM <br />SBD -6398 (R. 11/11) APR 13 2017 <br />Ll <br />17:. 1GIAICYT r�nl MTV <br />