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z c*f:3h <br />r� <br />Industry Services Division <br />County <br />r3 u.. ✓ V%19 4 ' <br />,Zr E SN <br />.>. <br />1400 E Washington Ave <br />9 <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />�� ✓ 9 2 <br />Madison, WI 53707-7162 <br />t7 <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 governmental 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 />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Berm he4 rd 4- <br />Parcel # <br />07- 0ao -d wo a a <br />�Ce-+Ale <br />9 (,-7s olJaoa <br />Property Owner's Mailing Address <br />Property Location <br />% U O �� �� <br />Govt. Lot <br />X, Section a� 8 <br />City, State <br />Zip Code <br />Phone Number <br />Web S�-f✓ lv5- <br />SY03 <br />(circle one <br />T HO N; R /6 E oC <br />II. Type of Building (check all that apply) <br />Lot # <br />i ` or 2 Family Dwelling - Number of Bedrooms 3 <br />l <br />�a <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 />�?Townof <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 />El 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 System/Component/Device: (Check all that apply) <br />5�wor Pressurized fn-Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holdin Tank ❑ Other Dispersal Component (explain) ❑ Pretreahnent Device (explain) <br />V: Dis ersaI/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) System <br />Elevation <br />tu-0 <br />, s <br />9a o <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />New Tanks <br />Existing Tanks <br />w <br />r <br />o <br />aU <br />- <br />co <br />vi <br />iDU <br />a <br />Septic or Holding Tank <br />Dosing Chamber., <br />+ <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 />Plu'mber,''ss Signature <br />NIP/MPRS Number <br />Business Phone Number <br />/�IG if h'o �Ci n s <br />%�%�-� 7'r <br />-/ <br />%°6 "/,S�% <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun !De artment Use Only <br />Approved <br />Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing t Signature G <br />e( 0/�' O 4 <br />i <br />El Owner Given Reason for Denial <br />- ! A <br />k� <br />/ �/ <br />lvJ <br />IX. Conditions of ApprovaVReasons for Disapproval <br />VS <br />W <br />G_Ls-l� <br />JUN 52019 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s t 1Iches <br />in'llzvQUrn@tt County <br />Land Services Department <br />SBD-6398 (R0313) <br />