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County .,1... <br /> Safety and Buildings Division ! of <br /> D *, 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> SRS ;j( Madison,W) 53707--7162 <br /> •yr. t E�J((..JJ <br /> .FJ <br /> ti <br /> Sanitary Permit Application sate Transaction Number <br /> In accordance with SPS 383.21(2),Nis.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 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),Stats. �'�� "t 5 <br /> 1;. Application Information—Please Print Alf information <br /> 40<7 <br /> Property Owner's Name parcel# <br /> U�'�, W y5 r� -40/Y 10 S �doN-al8ixa� <br /> Property Owner's Mailing Address Property Location <br /> 3� Govt.Lot 1 2 <br /> City,Sate � Zip Code Phone Number p y,, /yV,, Section <br /> °Zy <br /> rM fx� (r m9633S 12-237— 4I/y T yV N; R�1E�nro0/ <br /> 11.Type of Building(check all that apply) Lot# <br /> J;or 2 Family Dwelling-Number of Bedrooms 5 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Descrilie Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> vs Otey �Townof 60yrr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System 12 Replacement System ❑TreatmentJHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-Pressurizedln-Ground ❑PressuriudIn-Ground ❑At-Grade ❑Mound>24in.ofsuitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Applicatiod Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation <br /> 05� <br /> V L Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a U d .L <br /> NOV Tanks Existing Tanks a 2 r2 "d a <br /> Septic or Holding Tank Z06 <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) 1 Plumber'sSi ^ MPIMPRS Nmnbcr Business Phone Number <br /> o�g D�k ey T� $ �3 T/ -5de_-ozo Z <br /> Plumber's Address(street,City,Sate,Zip Code) J / <br /> Z 7z go 1QY/?r'�n! ge.14' t.J i SfBF <br /> VIII.Coun /De aliment Use Only <br /> Appmved ❑Disapproved Pettit Fee Date Issued I 'ng Agent Signature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anzcb to complete plans for the system and submit to the County only as paper not las than 812111 inches In du <br /> SBD-6348(R.11/11) <br />