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Attach to complete plans for the system and submit to the County only on paper not less than 8 IC x It inches in size <br />SBD -6398 (R0313) <br />CouR <br />Industry Services Division <br />`� ✓ <br />1400 E Washington Ave <br />9 <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />' s t �S <br />�N - �F -6S' CST -19-t <br />,:� <br />Madison, WI 53707-7162 <br />7 <br />5- -a. e#&W 768 <br />Sanitary Permit Application <br />State Transaction Number <br />N M — <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <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 Servies. Personal information you provide may be used for secondary <br />at q7 D 7 /✓7 t h e r ✓ot C t.Y <br />purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />ty-7-a3A-a <br />4 <br />Property Owner's Mailing Address <br />Location <br />Pat. <br />7.50 0 /V c � 6",X Rd • <br />Govt. Lot <br />y,, y,, Section <br />City, State <br />Zip Code <br />Phone Number <br />wp Od 6u✓t j/11 A/ <br />5364 <br />(circle one) <br />T y/ N; R I6 E or,'VV <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />I or 2 Family Dwelling - Number of Bedrooms 3 <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />[I Village ofry <br />CSIV Number <br />IdI Town of SW(.S.S <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />9 Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />El Permit Renewal <br />El 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 />dal 4/ ,I j —g,5— <br />8'SIV. <br />IV.T ype 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 />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />yra <br />. -7 <br />6 y3 <br />(p Iq it <br />93.9 IL g �► . 8 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units <br />o ,� <br />New Tanks <br />Existing Tanks <br />aUi <br />0 <br />y <br />ro <br />a U cn N <br />rn <br />Septic or Holding Tank <br />/m s -a <br />,IN /'i �f P p ]w ✓ <br />X <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) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />fZ ► r� Me /eI H1 <br />/?4,.4.,0 �/ <br />- <br />71s- Mrd - v J_7 <br />Plumber's Address (Street, City, State, Zip Code) <br />7 7/.. o , /, Y 141-e 6.S f.e L�� Sy r7 <br />VIII. Coun /De artment Use Only <br />pproved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />suing A�ignature <br />$ <br />3-2S <br />❑ Owner Given Reason for Denial <br />'- <br />IX. Conditions of Approval/Reasons for Disapproval <br />'�.44 . S cs 13Y) i IN In <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 IC x It inches in size <br />SBD -6398 (R0313) <br />