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1 0,klif s, County BM <br /> Industry Services Division ,D f M <br /> =/j Q ,��t • 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `_,: ` `trg`� �` P.O. Box 7162 <br /> 1`� PS / ` "i � ''�" Madison,WI 53707-7162 <br /> ... 3 v[(o — I�i(v <br /> ''��- -ter 1 —Z o0 <br /> `Ill % <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. 04— I <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Jerk-e_.9 go b -Q Awn n 0(o4/Og0q-io2- 5o-o <br /> Property(Owner's Mailing Address Property Location <br /> X4 tP Pi n On A Govt.Lot <br /> City,State Zip Code Phone Number NMI '/. 01\11/4, Section 10 <br /> DE RD rig- `� ' (c Ic one) <br /> VV T� N �:483 =E r\',' <br /> 11. ype of Building(check all that apply' ` C/ Lot <br /> WI or 2 Family Dwelling—Number of Aedroo ns t Sttbdrste to <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑State Owned—Describe Use ❑ Village of <br /> CSM Number ,--,/ A J 1_p y�n <br /> i 2 P2— 11Q Town of V "V� <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. INew System". ❑ Replacement 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 /> Non-Pressurized ln-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 Applica'ti/on Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation / <br /> SD l Rate(gpdsf) 0- -t / 1( D 5-- r 1(3S-- <br /> (3 / (iLI a <br /> VI.Tank Info Capacity in 8 <br /> C <br /> Gallons Total #of Manufacturer o h 0 �, y <br /> Gallons Units ` o 2 = .n <br /> New Tanks Existing Tanks n �0.(.j ,, C7 p., <br /> Septic or Holding Tank IC0O ' � 1OO?. k M.,g_at .C_ 11 ❑ ❑ ❑ ❑ <br /> Dosing Chamber SAO C-5° I t`UN,£ aJ2 c ID ❑ ❑ ❑ ❑ <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 Signature �— MP/MPRS Number Business Phone Number <br /> S.v�ln c) T- smei J a 6�.-�-,� Z2-1 I I to In013-4�7-52q-1 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> NIN58 c — o wox-fe v!ba u <br /> I , I 535 <br /> VIII. ounty/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date 1 :.ed Issm ignatt <br /> ❑ Owner Given Reason for Denial S -I 6 I 74//6 APP"-- ,_...odae--1 iA-- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than B 1/2 a 11 inches in size <br /> SBD-6398(R03/14) <br />