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nnl OnnAol ITcn rc%n n r,l►tr-r'% <br />I—— —.......1............. ,,..,..... ... — --y umy uv paper act less than C IR x l I inches in size <br />SBD -6398 (110313) <br />tvn <br />v t f_1VJ'liAl14114CU <br />County <br />Industry Services Division <br />I� <br />;yj <br />1400 E Washington Ave <br />9 <br />Sanitary Permit Numbpr� (to be tilled in by Co.) <br />P.O. Box 7162 <br />1.I§y1��1 <br />Madison, WI 53707-7162 <br />%Ht�fl <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(l)(m), Stats. <br />In' dfv 1- /� <br />I. Application Information Please Print <br />- All Information <br />w" 0 <br />Property Owner's Name <br />0A V P_ /`f a <br />Parcelft <br />67-018— <br />o,iJl mod <br />Property Owner's Mailing Address <br />Property Location <br />s -y(00 /99.4 ,q„e W;v <br />Phone Number <br />Govt. Lot <br />y, y,, Section ) % <br />City, State <br />Zip Code <br />NOtvAeN /" Al ,S.S3&-I(-turtle <br />one <br />T 391✓N; R /6 E oO <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />I or 2 Family Dwelling - Number of Bedrooms O <br />( <br />F 0 "t r ! <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned -Describe Use <br />[I Village ofb <br />CSM Num <br />Number <br />y 3 % 8 3 <br />nor <br />1J Town of In -CCH 6 ,'1 <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 />❑ 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 />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />N1 Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treat ent Area Information: <br />Design F* (bpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />° <br />o <br />New Tanks <br />Existing Tanks <br />o0o <br />/ <br />c U Cn n <br />A /ex Yr / <br />K <br />c <br />ci V <br />a <br />Septic or Holding Tank <br />36 <br />6OD <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br />,�% <br />/G /171b lG/h S `%=2�+f/ / aj �Sy �.S — �G6- z// -s 7 <br />PlumbAddress( treet, City, State,, Zip. Code) <br />7er <br />-'mss <br />7 / 6,!�) /5/ w <br />VIIl. Cour /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee 0 O <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />3 % <br />�Q"J ' 7 <br />IX. Conditions of Approval/Reasons for Disapproval <br />Q �/ <br />&9 /V GCGY./YI C/) = .9S*6 00 /1 �'S�iS � �e ILi e ALove, <br />I—— —.......1............. ,,..,..... ... — --y umy uv paper act less than C IR x l I inches in size <br />SBD -6398 (110313) <br />