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^""''t� Industry Services Division County ���-� <br /> /.,,,,,,,-,- ___ <br /> 4® )S,\ 1400 E Washington Ave ge <br /> 1;1 �`pp i" P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> : , Madison,WI 53707-7162 <br /> '� �■ f / 3-• fir? _ void 4. <br /> �'y�'Z„n�n(�1a <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pennit.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 (-1-v" f <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information w v <br /> S■ YN Prc C\ <br /> Property Owner's Name BA,yer Parcel# <br /> I JKe m fmaraare+ A Skc�. evche� /ty\4t�"1"c�,C�-� P10mmQ� 012106111-3O�I- 4c014-1- <br /> Property Owner's Mailing Address p Property Location <br /> Z(c,t , c cO`3c-e S S RC), Govt.Lot <br /> City,State Zip Code Phone Number SIN ,� Se /. 30 <br /> , Section <br /> CA(,C a l t S o!\ r Lt) 1 X3-7 I i c o o z Z I z. -33 7% (circl ne) <br /> T 0q N; R 1 1 (E�r W <br /> II,Type of Building(check all that apply) Lot# v <br /> 1 or 2 Family Dwelling-Number of Bedrooms y . 7 Subdivision Name <br /> Block# YOOV-S & d-& e S <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ,❑ Village of <br /> lVI"own or-70 1-- S i'a I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Pennit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Pennit 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 Ayound>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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> poo <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units t o'$ <br /> New Tanks Existing Tanks v <br /> li a 8 v 13 ` 0 <br /> a`u° in 0 in O is. <br /> Septic oi'I4otTng Tank I.ZC,Q — / 1 <br /> Za e 111 eaol.e ,/. <br /> Dosing Chamber goo — e: t I Iv\2-cic.e ) <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 ignature �-- MP/MPRS Number Business Phone Number <br /> `J�ev.e n ��SC��` C k� C- ,99 -cl, _ ez�►∎I 1,0 9z13 1478-Z3`7 9 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N8'( Co,,A.-1-, R 'o d 0� * r` (D o L31 S9`7/ <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit F e� Date Issued Issuing A e ign re <br /> ❑Owner Given Reason for Denial S /c t 1(0/' 5-.48-2,917 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ' /c f 7 T�w�rr ff /t( '7 <br /> PRo7Ec7 m°wro SYSr pr <br /> -,i,-No C°,40,- (. <br /> Piz°1 -7 F ' rwt- l f"\e/ - S% O-r... <br /> Mato 1/ 7 Cum -j c <br /> EIv. P r-2-•:. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 `iE to si <br /> I . p <br /> MAY 15 2017 a <br /> s°` <br /> SBD-6398(R.08/14) li -' '— ' <br /> Public Health MDC <br /> Environmental Health <br />