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—� ;;„ Industry Services Division C e/� <br /> ;,*, 1S`•, 1400E Washington Ave <br /> G <br /> h!-.,_' 5. P.O.Box 7162 S ary Permit Number(to be filled in by Co.) ■ <br /> _ ' ' Madison,WI 53707-7162 <br /> 13 d o, ov <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. kit o <br /> I. Application Information-Please Print All Information (1 i' ',A 4,P <br /> Property Owner's Name_D Parcel# tt <br /> Sate(Pt'a ,, <br /> 0 (2"I T.4—7erI `? <br /> Property Owner's Mailing Address Property Location <br /> 041- E 4,6-f,-.6 Pi Govt.Lot <br /> City,State Zip Code Log-Number 5t. v, SA— V.,Section /* <br /> vrrFm C_.) --- c 3S 3Y Logg-Z(2-g-c-,67 (circle one) <br /> D.Type of Building(check all that apply) ��// Lot# <br /> T S N; R 12 1 orw <br /> �Ior2 Family Dwelling-Number ofBedrooms !r- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ((i rlgc .g-Townof19/j,.../ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' c®'New System ❑Replacement System ❑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 Svstem/Component/Device: (Check all that apply) <br /> 2I-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.Dispersalfrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3a, • .:. Sao fo'f '16 S- 5'6 t v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °' <br /> New Tank Exi <br /> s sting Tanks t c i E <br /> w o <br /> iZ m <br /> a U in q Z ii V a <br /> Septic° Tank I .45, --, feat' ( a7.,,,,,„1 ...<...Dosing Clamber 6, cY•Z t 0/„t <br /> o.e-- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POW+S shown on the attached plans. <br /> Plumber's Name(Print) PI ignature MP/MPRS Number Business Phone Number <br /> grt.l.0 44 r0Soc-t ls,c,7:4/15") .?/20 LI 7 y 6CDS-757- 66S6 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 2( Gc„e 2 0,4..Q ; t-(am, , t,...)z s 7 c T 1 <br /> MVIII.County/Department Use Only ,/_(r_Q/�,, <br /> Approved ❑Disapproved Permit Fee Data Issued Issuin`� `��[//a'a <br /> $ 431 S4Q-20(7 <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> Attach in complete plans for the system and submit to the County only on paper not less than a tR x 11 inches in sire <br /> MAY 18 2017 <br /> Public Health MDC <br /> SBD-6398(R.08/14) <br /> SCANNED Environmental Health <br />