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Industry Services Division <br />NNED 1400 <br />v <br />G <br />E Washington Ave <br />N COMPUTERISC iI <br />Sanitary Permit <br />Box 7182 <br />Madison, <br />Co.)P.O. <br />Y <br />a 6q �i¢X#s'ia 3 <br />WI 53707-7162 <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 penniL Nobe: Application forms for state-owned POWTS <br />y <br />are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance with the privacy Law, 15. 1 <br />PrOJcet Address (if different than mailing address) <br />s. in Stats. <br />I. Application Information - Please Print All Information <br />27939 <br />7l=' <br />Property Owner's Name <br />Parcel # <br />Property Own ailing Address <br />Property Location <br />Govt Lot <br />City, State Zip Code Phone Number <br />+, '/., Section L� <br />' <br />II. Type Building <br />(circle <br />T4 -C) N R Eo W <br />I <br />of (check all that apply) Lot # <br />10 1 or 2 Family Dwelling - Number of Bedrooms <br />Subdivision Name <br />❑ Public/Commercial - Describe Use <br />rBlockState Owned - Describe Use <br />❑ City of <br />ber <br />❑ Village of <br />� <br />51 Town of 4/1 <br />III. Type of Permit: Check onlyone boa on line A. Com tete line B if a licable <br />A• New System ❑ Replacement System P Y ❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New <br />Before Expiration <br />List Previous Permit Number and Date Issued <br />Plumber Owner <br />IV. Vjpe of PO S stem/Com onent/Device: Check all that apply) <br />�] Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade <br />❑ Holding Tank ❑ Other Dispersal Component (explain) E3 Mound > vi in. of suitable soil <br />P Po { xp ) ❑Pretreatment Device (explain) <br />El Mound < 24 in. of suitable soil <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) Design Soil Application Dispersal .Area Required (sf) Dispersal Area Proposed (sf) System Elevation <br />Lq!' 0 Rate(gpdsf) y7 <br />l.� 67 `(7� <br />�� <br />VI. Tank Info Capacity in <br />Gallons Total # of o° <br />New Tanks Ex�}ng T Gallons Units Manufacturer o <br />Septic or Holding Tank I r , <br />� <br />Dosing Chamber <br />❑ ❑ ❑ <br />❑ ❑ ❑ ❑ El <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) Piumbe ' i r <br />Number Business Phone Number <br />4MP/MPRS <br />Plumber's Address (Street, City, State, Zip Code) <br />-� <br />�a ��'�C�o� S�� <br />Im Approved ❑Disapproved Perm�tF�ee D �Daftssued Issuing AgentSignature <br />❑ Owner Given Reason for Denial $3 . - 7 <br />IX. Conditions of Approval/Reasons for Disapproval <br />to complete plans for the system and sabmit to the Coanty only on paper not less than 8 1/2 x 11 Inches in siu <br />SBD -6398 (803/14) <br />