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Attach to complete plans for the system and submit to the Courtly only on paper not less than D M Ill inches to sae, <br />AUG 132018 <br />SBD -6393 (R. 11/11) LJNETT COUNTY <br />ZONINr, <br />Safety and Buildings Division <br />County <br />orive#- <br />X , fi; <br />` l <br />201 W. Washington Ave., P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />NN <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383 21(2), Vis. Adm. Code, submission of this form to the appropriate governmental unit <br />A <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 Safery and Professional Servies. Personal information you provide may be used for secondary <br />purposes in accordance %vith the Privacy Lav, s. 15.04(t)(m). Slats. <br />1% eye)/ <br />!! 6 ( 4 <br />I. Application Information — Please Print Ail Information <br />Property Owncr's Name <br />Parcel R <br />A,., ed ej�,�,e <br />07 040 <br />Property Owner's Mailing Address <br />Property Location <br />Z fj� bO t%1 ewCJ1 <br />Govt. Lot_, <br />y/.,, Section Zd <br />lconc) <br />City, State <br />ZipCode <br />PhoneN1u�mbe/r <br />''l�/' <br />7/�7 <br />c <br />T tif�N; REorN <br />H. Type of Building (checI: all that apply) <br />Lot i= <br />Subdivision Name <br />ff1 or 2 Family Dwelling —Number of Bedrooms <br />Block <br />❑ Public/Commercial —Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />C3 Village of <br />CSIA Numbers <br />OL <br />L <br />Townof <br />Ill. Type of Permit: (Check only one box online A. Complete Iine B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />Treatment/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 />S R,v. _�/a 7 - -� <br />IV. Type of POV*'TS System/Com onentlDevice: (Check all that apply} <br />❑ Non-Pressurized 1n-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound >_ 24 in. ofsuitable soil ❑ Mound <24 in. ofsuitable soil <br />P+ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersa)/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Ratc(gpdsf) <br />Dispersal Area Required (sl) <br />Dispersal Area Proposed (s <br />System Elevation <br />V3. T ank info <br />Capacity inTotal <br />r of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />U <br />s <br />a.U <br />g <br />in <br />= <br />rn t= 0 <br />a <br />e. <br />New Tanks EristingTanksi <br />Septic or Holding Tank <br />1 fM/►v ,t1n/ <br />1 4v� V�V <br />' 2 <br />7 <br />-7 <br />L••' <br />w <br />I <br />Dosing Chamber <br />VII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POti4TS shown on the attached plans. <br />Plum s Name (Print) J <br />Plumbc ' Signature <br />����/► <br />MPiMPRS Number <br />Business Phone Number <br />�� �C i~ nlr�e-- <br />Ss� �s�-' <br />lis- �c� -ozo z. <br />Plumber's Address (Street, City, State, Zip Code/ <br />Vill. County/Department Use OnI <br />Approved <br />❑ Disapproved <br />Permit Fee 0 <br />53 D <br />Date Issued <br />Issuing Agent 5i, re <br />7�". <br />— <br />y ✓�(� <br />❑ Owner Given Reason for Denial <br />/ <br />Ii. Conditions of Approval/Reasons for Disapproval <br />APPROV[D <br />0 E 0 V <br />Attach to complete plans for the system and submit to the Courtly only on paper not less than D M Ill inches to sae, <br />AUG 132018 <br />SBD -6393 (R. 11/11) LJNETT COUNTY <br />ZONINr, <br />