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.1eX Industry Services Division <br />Coun <br />ugh <br />r <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />S P.O. Box 7162 <br />FS <br />- � -1 <br />�� <br />�w Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />�t� <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <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 Servies, Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. <br />I N <br />I, Application Information — Please Print All Information <br />Property Owner's Name <br />p �Y <br />Parcel # O� /s /3 ^SDS <br />�,7 6,1II^ <br />E <br />0&(,—o//000 <br />Property Owner's Mailing Address <br />Property Location <br />9/ b 0 09&" b Yr <br />Govt. Lot 6 <br />/ /,, Section /3 <br />City, State <br />Zip Code Phone <br />Number <br />L w h r v l �>e / / / N7 �.�,O Pf <br />9S- <br />- ) 70" L% %/,6 <br />T � N; R /-S circlE cone l <br />IC1� <br />II. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />or 2 Family Dwelling — Number of Bedrooms 3 <br /># <br />Block <br />❑ City of <br />❑ Public/Commercial — Describe Use <br />CSM <br />El State Owned —Describe Use <br />❑ Village of <br />Town .)c• <br />Number <br />of <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 Moditication to Existing System (explain) <br />B. <br />El Permit Renewal <br />❑ Permit Revision <br />F] Change of Plumber <br />70Pnmit Tansfer to NewList <br />Previous Permit Number and DateIssued <br />Before Expiration <br />er <br />IV. ;iype of POWTS S stem/Com onent/Device: (Check all that apply) <br />`on -Pressurized In -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) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd)Design <br />Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />L-(,5-6?s <br />�o el <br />goo <br />�y•,t <br />Vi. Tank Info <br />Capacity in Total <br /># of Manufacturer <br />Gallons Gallons <br />Units <br />P <br />0 <br />a U <br />v <br />cn H <br />Y <br />rn <br />w U <br />a. <br />New Tanks <br />Existing Tanks <br />Septic or Holding Tank <br />/b t'0 <br />✓ <br />/ <br />1C K O✓ <br />x <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 <br />Signature <br />NIP/MPRS Number <br />Business Phone Number <br />LL//� <br />Plumber's Address (Street, Ctty, State, Zip Code) <br />V 11. County /1De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee O <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />syV(tln 2Li✓A A/ Clm,/l <br />.0 . ® OCT 0 1 2018 <br />%7 �� ??9.4 ons Jes.trc 4 1 f41 J#V `4A PPROVED <br />M11-- - - - <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 I/3 s i l inches m srze k+UUN I Y <br />ZONING <br />SBD -6398 (R0313) <br />