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RECEIVED <br /> .`,v:.r.'4), . County <br /> MAR V''2' 2016 Industry Services Division Q„re. <br /> D$ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> \ P P.O. Box 7162 <br /> $ Public Health MDC <br /> r`- Environmental Health Madison,WI 53707-7162 15- 204)-066 �c <br /> Sanitary Permit Application Slate 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 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),Suits. <br /> I. A Ton Information—Please Print All Information C L, -n+7 Q ), J <br /> Pro� ""rilName Parcel 8 <br /> airltrll�l� <br /> Property Owner's Marlin :ddress c,.o, .-. + Property Location <br /> 4-0-4: 9' /v.. -•-I-.Or&i:3 _-......9„. Govt.Lot <br /> ity,State ✓ <br /> �/ - +3rCn{ („ - Phone Number t t <br /> lr -..01"('-'Ih.)7-.z.:. .. t^<'.._. j /4, .`iL` 1/4, Section „� <br /> � <14.--�-r.. usi.■ S C <br /> C . S."3 -3-- 60 y) k'"is"-,S`3`4.5` T 6 N; R 7 E <br /> H.Type of Buildin (check all that apply) . Lot# v"-----., <br /> ®I or 2 Family Dwelling—Number of Bedrooms t j Subdivision Name <br /> �.__._...,' Block 8 <br /> ❑Public/Commercial—Describe Use <br /> .r ❑City of <br /> ❑State O++ved—Describe Use CSM Number ,✓ ❑Village of <br /> III.Type of Permit: (Check only one box on line A. Complete-•line B,if applieitble)--~- <br /> A. ®New System ❑Replacement System <br /> OTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• El 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 —.,'N <br /> ❑Non-Pressurized hi-Ground ❑Pressurized In-Ground at-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank Either Dispersal Component(explain) -' Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) ( Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Ta Info Capacity in I Total.. / r C'-i� .-- 1 :.t . .S-- . <br /> I ) of Manufacturer <br /> Gallons Gallons Units s ` o v u <br /> New Tanks Existing Tanks b U ti b r, <br /> o °-'• 2 e :ate 2 <br /> o.U cr, ., rn ti•.C7 d <br /> Septic or Holding Tank S rJ O uU <br /> Dosing Chamber 7.5'L <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 MP/MPRS Number Business Phone Number <br /> 7S0%'s f■ 1-1ticjc,^ <br /> 1-/(-- #01%------------„_„„--- cart. J- 7 u Plwnber's Address(Street,City,State,Zip Code) <br /> 3 �t (, •'�y) qty -�gurJ <br /> VIII.County/Department Use Only /� ,. <br /> 10 •pproved ❑ Disapproved Permit Fee Date Issued Issuitt's Agr rrtSigiia trFe / / <br /> ✓' <br /> ❑ Owner Given Reason for Denial S.2 f _ Jam. <br /> I\.Conditions of Approval/Reasons for Disapproval <br /> c : <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R03I3) <br />