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�Al!!. \ County r ila <br /> /4�', ',f Industry Services Division <br /> ,kr 'r°-�`.,.: 1400 Washington Ave <br /> ?- SCANNED Sanitary Permit Number(to be filled in by Co.) <br /> - - f� "� P.O. Box 7162 <br /> 5\ �A; Madison,WI 53707-7162 <br /> Sanitary Permit Application 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 Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 5, ii <br /> I. Application Information-Please Print All Informatit ECE1, /E Lk Q!^ e.¢ <br /> Property Owner's Name •• `` V L Parcel# <br /> 16,■' -( - Qc V` 11.v' MAY 132016 GS ri.,' Z- I . D5C) <br /> Property Own is Mat g Address Public Health MDC Property Location <br /> r J y Environmental Ho3itp <br /> vt. of I'/ �, <br /> C. , ate I t-( Zip Code Phone Number Y.,NC..; '/., Section l ■ <br /> mil/ C e one) <br /> ��lJ IL ■ i 1— S 4 T N ; R r W <br /> L ype of Building(check all that apply) Lot# ` J <br /> l' or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name • <br /> ❑Public/Commercial-Describe Use Block// <br /> ❑ City of <br /> ❑State Owned-*Describe Use Village of <br /> CSM Number <br /> Town of rV\,di v.L <br /> HI.T pe of Permit: (Check only one box on line A. Complete line B if applicable) l <br /> A. New System El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> N...Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> olding Tank ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(god) Design Soil App' ation Dispersal Area Required(sf) Dispersal Area Proposed(sf) yste ievation 6. 8 e•S <br /> Rate(gpdsf) y <br /> VI.Tank Info Capacity in <br /> V <br /> 15 <br /> Gallons •Total #of O <br /> D <br /> m La U ,, - <br /> Manufacturer o : H y <br /> Gallons Units B o <br /> 2 0 . <br /> New Tanks Existing Tanks <br /> n. U in 0 v) ii. 7 % <br /> Septic er-HIItdtngTank a 0\9O `J lQO/ ` � 0 ❑ ❑ ❑ <br /> ❑ <br /> Dosing Chamber ❑ ❑ ❑ El ❑ <br /> Vii.R onsibility Sty Cement- I,the undersigned,assume res nsibili nsrt'tallation of the POWT vn on the attached plans. <br /> Plumbe Name(Print) Plumber's Sig MP P Num er, Bus' ess Phone Number <br /> Plumbe' Address(Stre t,City,State Zip C de) <br /> C I u r t ti �C, 1/LCL 7 3 ZS_. <br /> VIII.County/Department Use Only <br /> 11.6..Lproved ❑ Disapproved Permit Fee r— D�,9 / ei - ' <br /> atte Issued Issuing Age t Sigh re❑ Owner Given Reason for Denial $ o1 7-�j <br /> IX.Conditions��Approval/Reasons for Disapproval J G A � cr'fcSQ /nr ?f- <br /> �` x mce/A6yr U-✓`413 of r e.-0-. S)'�C- ELI vt l T /�l. � pis' <br /> Air("Mc— C"Ne(7v.,. /1�7c�7 f 2,). S 2(L c'h'i/. T 04; C-14-- E�`c '"'f <br /> Attach to complete plans for the system and submit to the County only on paper not Icas than 8 In x 11 inches in size <br /> SBD-6398(R03/14) <br />