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./,;rirsrgi"1 , <br />Coun <br />Industry Services Division <br />y,. <br />1400 E Washington Ave P.O. Box <br />Sani Permit Number to be filled in by Co.) <br />� <br />Madison, WI 53707707 —7162 <br />(D � <br />^ <br />T�lVll/ <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 />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br /># <br />vim— ' 1 <br />/P°�a'r�cel <br />V / <br />Property Owner's Mailing Address <br />Property Location COO <br />Q <br />Govt. Lot <br />cute '/<,��"'/<, SectionZ-5; <br />City, State <br />Zip Code <br />Phone Number <br />(circle A) <br />T3? N R j 6 E ok± <br />Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />Cp_q' I or 2 Family Dwelling — Number of Bedrooms <br />❑ Public/Commercial — Describe Use <br />Block # <br />El City of <br />E]State Owned — Describe Use <br />❑ Village of <br />CSM Number <br />Town of <br />III. Type <br />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 Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />O <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />DesignF�I4w (gpd) <br />if L.r0 <br />Design Soil Application <br />Rate(gpdsf) -7 <br />Dispersal Area Required (sf) <br />Dispe al Ara Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # of <br />Manufacturer 0 o <br />Gallons Units o 2 <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />0001❑ <br />❑ ❑ <br />❑ <br />Dosing Chamber <br />❑ ❑ <br />❑ ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plu er' Name Print) <br />Plumber's gn re <br />MP/MPRS Number <br />) <br />Business Phone Number <br />°<- <br />� <br />Plumber's Address (Street, City, State, Zip Code) <br />VII. CounyA5epartmenedsre 6nly <br />Approved <br />❑ Disapproved <br />Perin itt7Fee <br />^ <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />$ 3/� <br />IX. Conditions of Approval/Reasons for Disapproval <br />1iisl- l�t�:���%v/a"ePlApre GoaeK DvtrC�l�s, <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br />SBD -6398 (803/14) <br />