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't= <br />Industry Services Division <br />County <br />13 u` r n e {� <br />ir. <br />1400 E Washington Ave <br />9 <br />Sanitary Permit Number (to be tilled in by Co.) <br />d <br />P.O. Box 7162 <br />Madison, WI 53707-7162� <br />�3 <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 pennit. 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 />d 387 ' <br />purposes in accordance with the Privacy Law, s. 1 5.04(1)(m), Slats. <br />CO R14 f Z?�6-9 <br />1. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # J y y a <br />0ao 0 00 <br />Property Owner's Mailing Address <br />Property Location <br />I,,/ I d 6 ,5 6 ? 70 it 1, 14ve <br />Govt. Lot <br />y y,, Section J y <br />City, State <br />Zip Code <br />Phone Number <br />/?Ivt✓ F^//s I,v1 <br />SYo Jd <br />'�JS 30-7 y33,4 <br />T 39 NR j ircleone <br />; E o y <br />11. Type of Building (check all that apply) <br />Lot # <br />® I or 2 Family Dwelling - Number of Bedrooms 3 <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned -Describe Use <br />❑ Village of <br />CSNI Number <br />® Town of 014 r$ h /4 nod <br />II1. 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 />El Permit Transfer to New <br />List Previous Pennit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS System/Component/Device: (Check all that appEl l ) <br />Non Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade 12 Nlound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holdin- Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal(/Treatment Area Information: <br />Design Flow gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />ys 0 <br />1 Y9 <br />/. o <br />s0 q <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />y <br />o p <br />New Tanks <br />Existing Tanks <br />v <br />i <br />c U <br />v h <br />n <br />^ C7 <br />a <br />Septic or Holding Tank <br />/ O O 0 <br />/60 0 <br />Dosing Chamber <br />(006, <br />Od <br />V11. 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/MPRS Number <br />Business Phone Number <br />lZicic #0 <br />L. <br />,Yl s <br />Plumber's Address (Street! City, State, Zip Code) <br />J _776 0 #w 3-5-- tv-6ks r Y ,- W - - s418 93 <br />III. County/Department Use Only <br />TApproved <br />❑ Disapproved <br />Permmit Fee <br />Date <br />Date Issued <br />Issuing Agent Signatu e <br />❑ Owner Given Reason for Denial <br />$ 3 7J . <br />%a. -3- 1 <br />IX. Conditions of Approval/Reasons for Disapproval _ <br />APPROVFrlD <br />In NOV 3 U 201 <br />Attach to complete plans For the system and submit to the County only on paper not less tin 8 Il'as 11 inches in size <br />LONIiNG <br />SBD-6398 (R0313) <br />