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State Transaction Number In accordance with SPS 383. 21 2 Wis. Adm. Code submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. County Safety and Buildings Division 201 W* Washington Ave. P. O. Box 7162 Madison WI 53707 7162 Sanitary Permit Number to be filled in by Co. Note Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law s. 15. 04 1 m Stats. Project Address if different than mailing address I. Application Information Please Print All Information Property Owner s Name Parcel Property Location Govt* Lot City State Zip Code Phone Number Section circle one T N R E or W Lot II. Type of Building check all that apply Subdivision Name 1 or 2 Family Dwelling Number of Bedrooms Block Public/Commercial Describe Use City of State Owned Describe Use Village of CSM Number Town of III. Type of Permit Check only one box on line A. Complete line B if applicable A. B. New System Replacement System Permit Revision Permit Renewal Before Expiration Treatment/Holding Tank Replacement Only Change of Plumber Other Modification to Existing System explain Permit Transfer to New Owner List Previous Permit Number and Date Issued IV. Type of POWTS System/Component/Device Check all that apply Non-Pressurized In-Ground Holding Tank Pressurized In-Ground At-Grade Mound 24 in* of suitable soil Other Dispersal Component explain Pretreatment Device explain V. Dispersal/Treatment Area Information of Units Manufacturer Existing Tanks Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I the undersigned assume responsibility for installation of the POWTS shown on the attached plans. Plumber s Name Print Plumber s Signature MP/MPRS Number Plumber s Address Street City State Zip Code VIII. County/Department Use Only Approved Disapproved Permit Fee Date Issued Issuing Agent Signature Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval 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 SBD-6398 R* 11/11 Business Phone Number Plastic New Tanks Total Gallons System Elevation Fiber Glass Capacity in VI. Tank Info Dispersal Area Proposed sf Steel Site Constructed Design Soil Application Rate gpdsf Prefab Concrete Design Flow gpd. Note Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law s. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law s. 15. 04 1 m Stats. Project Address if different than mailing address I. Application Information Please Print All Information Property Owner s Name Parcel Property Location Govt* Lot City State Zip Code Phone Number Section circle one T N R E or W Lot II.

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