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r1AaTafftA, <br />Safety and Buildings Division <br />Lowuy� 1 1 _ <br />U rl'1 C. <br />J• <br />Y ; 1400 E Washington Ave <br />Box 7162 <br />San Permit Number (to be filled in by Co.) <br />S�,YU-I <br />P.O. <br />�� 3 j Madison, WI 53707-7162 <br />J <br />'t- 3� /_ O� ?9-5 <br />`' f �rx��a�� <br />State Tmnsactioonn Number <br />Sanitary Permit Application <br />3133ya8 <br />in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />forts for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application <br />Personal information you provide may be used for secondary <br />the Department of Safety and Professional Services. <br />purposes in accordance with the PrivacyLaw, s. 15.04(1 <br />/ <br />Parcel # <br />1. Application Information — Please Print All Information <br />Property Owner's Name <br />Location j�z jc o <br />f <br />Property Owner's Mailing Address <br />/ Z 6 <-_5 �5__ +e z/g <br />!� <br />Govt. Lot <br />c _ <br />City, State Zip Code Phone Number <br />c- `E ' /4, Section / <br />vc /., ��� <br />,c , <br />Jr 67 // c�J' / - , rS SJ / <br />(circle one <br />T j �1 N; R E o <br />11. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />I or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />❑ Village of <br />CSM Number <br />❑ State Owned - Describe Use <br />9' Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' C9 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />B. <br />❑ Permit Renewal <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stem/Com onent/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade E1'Mound >_ 24 in. of suitable soil <br />❑ Mound < 24 in. of suitable soil <br />❑ Bolding 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) Dispersal Area Proposed (s() System Elevation <br />ys' a <br />VI, Tank Info <br />Capacity in <br />Gallons <br />Total # of Manufacturer <br />Gallons Units <br />O U <br />a <br />3 o °«3 <br />n[' l coy a�/U rn H rn w c7 a, <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />Dosing Chamber <br />& tr <br />r• <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plum Name (Print Plu s Si ure� MP/MPRS <br />OLr, ��;�-- <br />Number Business Phone Number <br />%s• sze -mss <br />6 'rf 160� <br />i3sts,sl � <br />Plumber's Address (Street, City, State, Zip Code) _ <br />Vlll. County/ artment Use Only <br />Permit Fee Date Lssued Issuing Agent Signature <br />Approved ❑ Disapproved $ o p q <br />37S Q 7 <br />C1 Owner Given Reason for Denial �c <br />IX, Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />Q /J (� <br />ECDEU V (� <br />Attach to complete plans for the system and submit to the County only on paper not fess than S 1/2 x incr 2U�UU] <br />SBD -6398 (110313) BURN ETT COUNTY <br />l0Nli NG <br />