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v.a71(e.v\\ Count /// <br /> 4:•,, Industry Se rvices Division / � <br /> ,/ : D �` `} 1400E Washington Ave <br /> s; $P I`f Sanitary Permit Number(to be filled in by Co.) <br /> ,, S Irv•; P.O. Box 7162 <br /> Madison,WI 53707-7162 (J�, <br /> \.�fE`�11U�At�/ 13 r20I�— `i—3 f 2- <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(I)(m),Stats. <br /> 1. Application Information-Please Print All Information <br /> 1 Property Owner's Name Parcel# <br /> I <br /> • ('A-cry Lop,0 ce 2/4)72 -ov--1-2 - D _ <br /> Property Owner's Mailing Address /► / Property Location <br /> 7st /?�/�',CfI�G� 17i, _ Govt.Lot <br /> City,State --Ziptexe Phone Number 51/4) ''A, )W 'h, Section 3 <br /> Few w c35-3Y T N , R I'z(circl T,e) <br /> II.Type of Building(check all that a ly) Lot ft <br /> - <br /> ❑ I or 2 Family Dwelling-Number of Be rooms 3 Subdivision Name <br /> ❑ Public/Commercial-Describe Use_-_ Block II <br /> ❑ City of <br /> ❑State Owned-Describe Use ❑ Village of <br /> CSM Number <br /> I Z goy Town of r <br /> r7 i en <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System -Reeplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ZrNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �( Rate(gPdsf) f r/2 c (( 2$ -n=t ov 3z 2r.-1C O -0 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of v U •` ' <br /> Manufacturer <br /> Gallons Units ° a °: 2 <br /> New Tanks Existing Tanks ,U CZ H v L- C7 a. <br /> Septic oF 4•141.4-fank 1.-- 0o .... —a 13a2 1 11i(/Als`/'!rry 14 ❑ ❑ ❑ <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) Flu Lure MP/MPRS Number Business Phone Number <br /> /U�c uVs'nn <-- 04 1.' c1 -75 I- 65-6 <br /> Plumber's�Address(Street,CCity,State,Zip Code) �_r �� <br /> VIII. County/Department Use Only <br /> ..Approved ❑ Disapproved Per a.Fee �-/ Date Issued Iss g At. nt Sir/attire <br /> ❑ Owner Given Reason for Denial $ (/7 to.(9, /.5— i� A.v/ ✓/4, <br /> X.Conditions of Approval/Reasons for Disapproval �, <br /> I I <br /> iT � <br /> �ff 40;14101‘6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/r x I I inches in size <br /> SBD-6398(R03/14) <br />