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.r""°"t r, s S ices Division County <br /> �--_�� A I__. FIVE <br /> Y(B "} 1400 E Washington Ave p Clt� ._ g. <br /> vl r y " AUG 19 1p�g P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 7. � ./ Iv)"adison,WI 53707-7162 <br /> '-'4'." so P blic Health MDC 19 -63.4.1/ 0'j1,�.. <br /> Sanitary Tierml'eAl pp L on State Transaction Number <br /> In accordance with SPS 333 21(2),Wis.Mm.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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. <br /> I. Application Information-Please Print All Information .3 7(I'\o) g.C! - <br /> Property Owners Name Parcel# <br /> I <br /> da.or\ C, vJQnot.utk .Tekn,tifQ--r K We_ndaC� U(a I ( -z^] ! •- 215 -3 <br /> Property Owner's Mailing Address Property Location <br /> ZS 1 ) S r`,�� kA Dr. <br /> 4 - <br /> Govt Lot <br /> City,State `Lip Code Phone Number j'43 y, /0 t, y,, Section Z--7 <br /> S�O uoir kV() LL) - CJ 1 ircle one) <br /> T 62 N; R 1 t E or-W- <br /> D.Type of Building(check all tha ..pl Lot# <br /> 14 1 or 2 Family Dwelling-Number of:-. .oms -3 1 Sabdivisiea-Neeme <br /> Block# mss ; <br /> ❑Public/Commercial-Describe Use — <br /> ❑ City of <br /> ❑State Owned-Describe Use CStvt Number ❑ Village of <br /> CD%08-2, U Town of Ple.a.Sck n`4 Seq- 9S <br /> III.Type of Permit: (Check only one box on Iine A. Complete line B if applicable) <br /> A. " New System ❑Replacement System y p ys ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> ❑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 /> 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)_ ❑Pretreatment Device(explain) _ <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> LISb ©.4 // 25 ((3S 91.$' 43.'3' a3,S` <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 5 E <br /> New Tanks Existing Tanks E o f G <br /> 00 rn B O U yr �, to c. C.5 ..., <br /> Septic orFlelding Tank l b e 0 - 1 100 1. !ne'gttc_ X <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> S ev <f\ 'Ti S i•N /AAA-c.v. ,(,,, 0^- z-Z3 1 1 to (3-Lc5 49 g- 231 1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> B L\5 Cr e'_` C..00 ■-k-y 1-- w`i O f 1' 0.\f v\,3 o t 1 r i i S 3 5 q `f <br /> VI County/Department Use Only <br /> VI <br /> ❑Disapproved Permit Fee <br /> Date Issued Issuing rapSi azure <br /> ❑Owner Given Reason for Denial S L/407: e-22--2/6 <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 8 I/2 x11 Inches in size <br /> SBD-6398(R.08114) <br /> • <br />