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,,,,,.r,.�,,. County <br /> RECEIVED <br /> MAR 11 2016 Industry Services Division tti^fz <br /> Do 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P$ Public Health MDC P.O. Box 7162 i�� <br /> Environmental Health Madison,WI 53707-7162 ( •7- 2_0 1‘._����.J 55- <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stets. <br /> I. Application Information-Please Print All Information C 0 n ii R.0, r J <br /> Property Owner's yName �+ /f Parcel# 7 /� (� L �`` <br /> kte.Ae •71` 2uJt? • '�vei " t7>�K4i /eo.s.st), V 0601• - 2I- 5O' <br /> Property Owner's Mailing Address Property Location <br /> 3 O .S 7 /V , S t.-4—\0^ R;,mow' Govt.Lot <br /> City,State Zip Code Phone Number <br /> 5 ( '/a, e '''A, Section A <br /> V4."0"'‘,... , (.0.1 SC • S- 3•)-Ci 3 0:00 to �s'�1, -S-3e-f_S- T (, N; ft 7 E <br /> II.Type of Buildinf(check all that apply) Lot 4 <br /> AI or 2 Family Dwelling-Number of Bedrooms Li Subdivision Name <br /> Block it <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of `` <br /> ®Tows,of S el'■0.) Ctn.14, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. News stem 0 Replacement System 0 Treatment/Holding Tank Replacement Only ['Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device; (Check all that apply) <br /> 0 Non-Pressurized h,-Ground ❑Pressurized In-Ground 04t-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) _ OPretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) ' Dispersal Area Proposed(sf) System Elevation <br /> (0 O0 O •(p L2 00 62 6 e Llj;.1 . $•-C; <br /> VI.Tank Info Capacity in Total if of Manufacturer <br /> Gallons Gallons Units D V o'P u <br /> New Tanks Existing Tanks rs u U <br /> n.U iz H v, u-V a <br /> Septic or Holding Tank <br /> ia00 l3c'c'' 1340 I De..ir...,r,.,„../ X <br /> Dosing Chamber 7 S Z <br /> 7J.0 iG.l w.c., cry 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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> -"S.Q�.r‘ lacy<„ti r ! ..___ _ a2.3 5 7 C (4u4s) 96 7-.2 3 vg.) <br /> Plumber's Address(Street,City,State,Zip Code) <br /> t <br /> G. 2 t{(,•) L.,,,,r.1y a...3. O'0 NA,-.∎ ne-rc--1. 1 P.r T- I w 4 S C. . S 3 S ea,c <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent <br /> ❑Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial 72 }GJfj <br /> I\.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the Comity only on paper not less than 8 112 a I I inches in size <br /> SBD-6398(R0313) <br />