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`r� �4,F Industry Services Division County <br /> y,ls";: ., ... 1400 E Washington Ave 5)01/4V1 Q.- <br /> N ) `"'' 1 P.O.Box 7162 Sanitary Pctmit Number(to be filled iu by Co.) <br /> $ Madison,WI 53707-7162 <br /> 13- 2015 -0°37 <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary (c,q F1der I.-rr . <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information 5u r. Pr0.1C‘, e <br /> Property Owner's Name Parcel# <br /> rtho'Cts 3. )Q'O oast-2z4 - 95)) 0 _0 <br /> Property Owner's Mailing Address Property Location <br /> 2115 f(a,,>J K S Nowen Tr 1 Govt.Lot <br /> City,State Zip Code Phone Number 6€ y,,SE; V., Section ZZ. <br /> De_Cta e 'k- 1 Lot 535 32 (008 22_0- 1 975 T —9 N; R )tcircleon�e <br /> H.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> 4",��' t Block# <br /> 13 Public/Commercial-Describe Use 1ir�C""'ro-4-/(3O%r <br /> ❑City of <br /> ❑State Owned-Describe Use CSlvl Number ❑Village of <br /> /3 q cp 031 Town of Z I"SA CA <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ys p y O Treaunent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> /3. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Perm it Transfer to New List Previous Permit Number and Date Issued <br /> • <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-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) III Pretreatment Device(explain)to•tie Knit. NJ,U: <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Prrnticed(sf) System Elevation <br /> 3G 6247 0,$ i4586,„-a.5 - ytS9s','10 941.714e F9q.3ii-�ll <br /> VI.Tank Info Capacity in ' Total #of Manufacturer <br /> Gallons Gallons Units a l'' �'$ ti " <br /> sor C'lrnl� New Tanks./ .,. Existing Tanks " 6♦ I i4$R r_ u o 2 , a s F <br /> 9 u in y to i= 3 c, <br /> Greatse L fr�ert ePtt f zoo o ZbOtD I L,j 5e c <br /> Septic or Holding Tank q ZO 0 q2©O '3 (,�,t tLSe- c X _ <br /> Dosing Chamber 1000, 1000 ( uJ;e_S Q` X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Plumb .s Signature MPlMPRS Number Business Phone Number <br /> .1.ev il._r -re S Ir QC- iL,��/911/4 Z:2-1 1 1 le, (32.c Le 18- 23 7 9 <br /> Plumber's Address(Street,City,Suite,Zip Code) <br /> e1\ 5e Co r,+`1 \-\k•.>„) 0 100.. .ev\0o , W1 s35"gy <br /> VIII.Countv/De.arttnent Use Onl I -...— <br /> Approved ❑Disapproved Permit Fee <br /> �J Date Issued Issuin <br /> ❑Owner Given Reason for Denial S 2 3// // ,3 d /, ��•I� ��_ �® <br /> IX.Conditions of Approval/Reasons for Disapproval _. <br /> () <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ill x 11 inches in size <br /> SBD-6398(R.08/14) <br /> .v <br />