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SCANNED • <br /> Corr011447 Industry Services Division County <br /> ' ;:,. 1400 E Washington Ave ni4g <br /> a ?—i s '.'t P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> „ Madison,WI 53707-7162 <br /> ' x /3—tors_ oc,rs ¢- <br /> Sanitary Permit Application State Transaction Number <br /> In accordance • , SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit <br /> is required psi• , obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffinent than mailing address) <br /> the Depattm . o Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in • • •ce with the Privacy Law,s.15.04(l)(m),Stats. <br /> L,. Applicati.n ,t ormation=Please Print All Information <br /> Property•• . .'s i ame Parcel# <br /> P r i . _milk 0907-054- $300'-3 <br /> Property a ....' t ailing Address Property Location <br /> 777 • -1-lif'4 y i 4 ed. Govt.Lot <br /> City,State Zip Code Phone Number kt y., 5 r V., Section 5 <br /> 340 ■ 0.;7r (Al t 33S7S !'v08 -643-279? T 9 N; R 'rtIIeW <br /> Ii Tx.e of : -ding(check all that apply) Lot# <br /> &T or 2 F... y t clung-Number of Bedrooms / Subdivision Name <br /> Block# <br /> G •.... ....... ial-Describe Use <br /> ❑City of <br /> •❑State Own:.-aescribe Use CSM Number ❑Village of n <br /> Et-Io'wn of KO P34 A Ili <br /> M.Type of 'e mit: (Check only one box on line A. Complete line B if applicable) <br /> A. E 11- S tem ❑Replacement System ❑Treatment/Holding Tank Replacement Only Q Other Modification to Existing System(explain) <br /> B. ❑P....'t•enewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before x iration Owner <br /> IV.Type of'I S System/Component/Device: (Check all that apply) <br /> - S Press • d In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding T.. ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispers: eatment Area Information: <br /> Design Flow(...'t Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> _ (50 . 6 260 aso q z.s <br /> VI.Tank In o Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o u <br /> New Tanks Existing Tanks c .Vi u 8 k <br /> 0 <br /> 0.U in y cn �L G <br /> Septic orHold' :T.k a 5o 8SO Wie_sen i/alYLck <br /> Dosing Chambe F,frefL_ <br /> VII.Respo 1.ib ity Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plueis N...e Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> _ir19 ELsi,J �' 1605477 4�' tf3Z -� 8K7 <br /> Plumber's Ad, e•:(Street,City,St te,Zip Code) <br /> 113r `7 CRi e r)-t?L Rd 13A10146a, td. 83713 <br /> VIII.Conn I epartment Use Only <br /> Dyed ❑Disa ved Permit Fee ::.Date Issued Issu".•A gnature <br /> ❑Own Given Reason for Denial S 00u/ <br /> 5-Z 7-l r/ ` X . <br /> IX.Conditi■ns of Approval/Reasons for Disapproval <br /> Attack to complete plans for the system and submit to the County only on paper not less than$112:11 Inches in size <br /> SBD-6398 ' 141/14) <br />