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ON COMPUTERISCANNED <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/3 s I l inches in size <br />ZONING <br />SBD -6398 (P0313) <br />Industry Services Division <br />County <br />�31 vin ell— <br />xt i� <br />`t <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P <br />P.O. Box 7162 <br />j Oa/ '' <br />6 <br />,rx;� <br />2 <br />Madison, WI 53707-7162 <br />GGA <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 govemmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />Q �9 <br />purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. <br />BAP Z?� <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />07-cy28=1-'lo�Iy 09.5"0,-- oo,t <br />�) �^ d ti Ile- tie I- r l.S <br />, IDA I vcoo <br />Property Owner's Mailing Address <br />Property Location <br />S / d 14 04 s A w e Or <br />d <br />a2 <br />Govt. Lot <br />y,, Section Cl <br />City, State <br />Zip Code <br />Phone Number <br />y� N <br />C <br />.5.� �! I <br />T N; R �� /(circlE or <br />g <br />If. Type of Building (check all that apply) <br />Lot # <br />® l or 2 Family Dwelling - Number of Bedrooms `J <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />Town of .SCOilr� <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />,K Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Moditication to Existing System (explain) <br />B. <br />El 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 />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />,RNon-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil <br />❑ 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) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (sY) System <br />Elevation <br />4�S-v <br />S -''i <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units <br />y <br />o -p <br />U <br />New Tanks <br />Existing Tanks <br />0 <br />c, <br />U cn <br />cF. U a <br />Septic or Holding Tank <br />.vQ / <br />Dosing Chamber <br />d <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name',(/Print) <br />Plumber's Signature <br />NIP/MFRS Number <br />Business Phone Number <br />le <br />// <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun /De artment Use Only <br />Approved ❑ Disapproved Pertnit Femme 0 Date Issued Issuing Agent Signatu <br />S 0_� <br />❑ �" g' <br />Owner Given Reason for Denial _ <br />' <br />IX. Conditions of Approval/Reasons for Disapproval <br />SEP 15 2017 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/3 s I l inches in size <br />ZONING <br />SBD -6398 (P0313) <br />