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CST 1�-loC <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 V± ill inc in Ale MR I U v i <br />BURNET'T (' It 1,fq -y <br />SBD -6393 (R0313) ZcNi"IQ <br />Industry Services Division <br />County /AX a. <br />�3u P'N -e� lggf l <br />1400 E Washington Ave <br />9 <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />SAYV- %$-a3 <br />Madison, WI 53707-7162 <br />/- <br />6a 7Q 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 (1f rliffrrrnt than mailinrr 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(I)(m), Stats. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # -67-s /S— <br />AI1-eo e lie <br />-10 -, 0 S' OBD <br />Property Owner's Mailing Address <br />R <br />Property Location <br />�9 69& er;- y //��, R; 0 e� <br />Govt. Lot <br />Phone Number <br />City, State Zip Code <br />y, y,, Section <br />OeS k, bU.r 6—Y�%3� <br />((circle one <br />T �!D N; R /fo E o 4 <br />II. Type of Building (check all that apply) <br />Lot # <br />29 1 or 2 Family Dwelling — Number of Bedrooms <br />Subdivision Name <br />Block # <br />Q. r �' vel �N <br />ElPublic/Commercial —Describe Use <br />❑ City of <br />❑ State Owned—Describe Use <br />❑ Village of <br />CSM Number <br />��tt <br />® Town of 66L le /Q N <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />(� Replacement System <br />❑ Treatment/Holdin g Tank Replacement Only <br />[I Other Modification to Existing System (explain) <br />B• <br />El Permit Renewal <br />Pen -nit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />( <br />X13 3 90 /,0-/; ` 817 <br />IV. Type <br />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 />DesigrFlow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />LIS -0 <br />: -7 <br />643 1 <br />6Y8 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units � <br />U � <br />New Tanks <br />Existing Tanks <br />y o <br />n, <br />Y a <br />a0 <br />nti <br />rn wU <br />Septic or Holding Tank <br />1i� 00 <br />b d0 j �� YSYv jl <br />Dosing Chamber <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 Signature MP/MPRS Number Business Phone Number <br />/Zr le j�o lel H ��� G '�-- a� S �9 X45 =�6 6- i' k5 7 <br />Plumber's Address (Street, City, State, Zip Code) <br />)7 __10 , W -eSs yY .t- <br />III. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Feed OD <br />$v <br />Date Issued <br />Issuing Agent Signatu <br />iff <br />❑ Owner Given Reason for <br />7Y, <br />�� Y ^140" <br />Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />u�E <br />nECEJ <br />ril <br />...W ;n 1.^.w <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 V± ill inc in Ale MR I U v i <br />BURNET'T (' It 1,fq -y <br />SBD -6393 (R0313) ZcNi"IQ <br />