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D'""E"RAT"I in4tr2018 UU <br />BUR <br />Coljr\iTY <br />SBD -6398 (R. 08/14) <br />Industry Services Division <br />Cou <br />' <br />1400 E Washington Ave <br />� <br />P.O. Box 7162 <br />S ni Permit umb <br />ry (t be filled in by Co.) <br />��`'� <br />Madison, WI 53707-7162 <br />f <br />s UTiS-aqo <br />Sanitary Permit Application ieation <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 />A1/4 <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if ditferent than mailing address) <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, s. 15.04(1 m), Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's ame <br />Parcel # <br />+ <br />Property Owner's Mailnig Address <br />Property Loca ion rn� ©� <br />9 <br />L5 <br />Govt. Lot <br />Section % Q <br />C�it/y�,� tate <br />W1 <br />Zip Code <br />Phone <br />[,Number <br />• Y e,' <br />�J <br />�+� <br />/� J 7- 2role <br />oi <br />r �rl/ <br />N, R E <br />II. Type o Building (check all that apply) � <br />Lot # <br />Subdivision Name <br />1 or 2 Family Dwelling- Number of Bedrooms <br />❑ Public/Commercial - Describe Use <br />Block # <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />Town of <br />III. 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/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 />OHmer <br />-� <br />IV. Type <br />of POWTS S stem/Com onent/Device: Check all that apply) <br />)kNon-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) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispers Area ProJ'sI)Sysaation <br />�VI. <br />Tank Info Capacity inTotal # of ManufacturerGallons <br />Gallons UnitsNew <br />Tanks Existing Tanks <br />Septic or Holding Tank <br />Dosing Chamber <br />VI 1. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name Print) Plumber' i ature MP/MPRS Number Business Phone Number <br />\ <br />Cie �� <br />Plumber's Address (S ree , City, State, Zip Code) <br />W70L3 kcxL W <br />Vlll. County/ eartment Use nl _1 — <br />Approved <br />El Disapproved <br />Permit Fee <br />Z A <br />Issuing Agent Signature❑ <br />Owner Given Reason for Denialf <br />=Issued <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />Attach to comntrtc .lane f— tho a.,eto....,..a o..w...:..,..�_ r <br />D'""E"RAT"I in4tr2018 UU <br />BUR <br />Coljr\iTY <br />SBD -6398 (R. 08/14) <br />