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Atach to complete plans for the system and submit to the Counh• only on paper not less than S las 11 inches in size <br />SBD -6393 (R. 11/11) <br />Safety and Buildings Division <br />County <br />V/Ne/ <br />Sanitary Permit Number (to be filled in by Co.) <br />201 VV. Washington Ave., P.O. Box 7162 <br />..f <br />Madison, Wl 53707-7162[cl <br />i <br />13 <br />sanitanj PC-, nit Application <br />State Transaction 'Number <br />/v <br />In accordance +.vith SPS 383 21(2), Nis. Adm. Code, submission of this form to die 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 />purposes in accordance with the Privacy Law, s. 15.04(t)(m), Stats. <br />Zi�� / AZI <br />F <br />I. Application information — Please Print A -1I Informmtion <br />Propem, Owners Name <br />Parcel <br />Z k <br />7 o1i10 /D / - - Fo - uv U 2 <br />Property Owner's Maailing :address <br />Property Location <br />120— / .56 Za /C L /✓ <br />Govt. Lot <br />SW V., SW ection <br />%El, Section <br />City, State <br />Ziip`Co�de�///, Phone <br />Number <br />, <br />T576T <br />jeon <br />c �r4"4/ <br />IN; R r <br />H. Type of Building (c ecic all that apply) Lot <br />Subdivision Name <br />1 or 2 Family Dwelling —Number of Bedrooms <br />Block <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />CSIM <br />❑ Stare Owned —Describe Use <br />❑ Village of LL �/ _ ]�T <br />���/ 11?AJC1 <br />Number <br />CVTotvn of / <br />Ili. Type of ?ermit: (Cheer: only one box online A. Complete line B if applicable) <br />A. <br />❑ New Spstent <br />❑ Replacement System <br />Treatment/Holdina Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber❑ <br />Permit Trtnsfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS SystemlComponent[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 />�'. Dispersal/Treatment Area information: <br />Design Plow Npd) <br />Design Soil Application Rate(,-pdso <br />Dispersal Area Required (so <br />Dispersal Area Proposed (sl) <br />System Elevation <br />Vi. Tank info <br />Capacity in <br />Total <br />of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />New Tants Fnsting Tanks <br />u a <br />u <br />J <br />Li <br />✓ <br />L <br />G <br />Septic or Holding Tar:1 <br />/// <br />11066 <br />I <br />Zj <br />Yy <br />; <br />Dosing Chamber <br />V-111. Responsibility Statement—!, the undersigned, assume responsibility for installation of the P01 TS shown on the attached plans. <br />Pluni s Name (Print) <br />Plumber's '_ turc� <br />MPtT�iPRS Number <br />N <br />Business Phone umbcr <br />Plumber's Address (Street, City, State, Zip Code) <br />v, i T. County/Department [.Tse Only <br />Approved <br />❑Disapproved <br />Permit Fee <br />5Z/ <br />Date Issued <br />Issuing Agent Signature <br />C1Owner Given Reason for Denial <br />, 0O <br />w <br />4 '"oZo �0 <br />(i. Conditions of Approval(Reasons for Disapproval <br />Atach to complete plans for the system and submit to the Counh• only on paper not less than S las 11 inches in size <br />SBD -6393 (R. 11/11) <br />