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.`"•rarui%. - C�ty <br /> Industry Services Division - J,P1 <br /> Y: 0 s 7 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P S P.O.Box 7162 <br /> Madison,WI 53707-7162 <br /> '',,-' •-_"`' 13-+on- o a elt-flo <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 pent 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 Projax Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. Q <br /> I. Application Information-Please Print All Information (c)1 C) IAA,V1 S <br /> 1 1 <br /> .,,erty,O�'s Name Parcel# <br /> c ( eS Vo,p,' <br /> l r��Ct `k 6-4c - 3�fr'S 0144— 05010 204- x'210, -2-' <br /> Property Owner's Mailing Address A Property Location <br /> 3 3 .-V-c c-1,\ U\- Govt.Lot <br /> City,State Zip Code Phone Number ] 'Y4, St: 'A, Section L) <br /> iAci.c Seri W 3 7 � i5 L (crone) <br /> f � � T ,j N ; R IvW <br /> IL Type of Building(check all that apply) `• Lot# <br /> `J I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use — Block if <br /> ❑State Owned-Describe Use ❑City of <br /> E1 CSM Number Village of <br /> 10 Town of e, <br /> t_,iii <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to F:idinE System(explain) <br /> t(N hike j- nt LJ h ot,i..-{-o .01 114.3 S <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 /> 8 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Gr <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Disposal Area <br /> ���� spersa Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in <br /> Gallons s' <br /> Total #of � ) c $ <br /> Gallons Units Manufacturer w H <br /> New Tanks Existing Tanks a U ..1).un run ii(V a <br /> Septic or Holding Tank /COO /000 I 14 ❑ Q ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned, , responsibility for instal n of the WTS shown on the attached plans. <br /> "'Amber's Name(Print) Plu i 's S .■ MP/MPRS Number Business Phone Number <br /> ('� LovelaC� Z2(08S2_ (0 23-ki',S-3"319 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V I.County/Dep rrtmeat Use Only ' '11 <br /> ppmroved ❑ Disapproved Permit Fee Date u [swine Ag --,,Cam,+ <br /> ❑Owner Given Reason for Denial S (ICI Y 2 1 <br /> .Conditions of Appronsans for Disapproval <br /> ti. <br /> I4L 4J i 4�+� 1 1 t.cfvp,Aw,li-(-aLE__€s ;EA //KIii—� e v f•='- L L <br /> C- ti- QvT-P'-c.,''��•s�S , / JUL 2 6 2017 <br /> Attack to complete plans for the system and submit to the County edy on paper not less than a in z It inches in size <br /> SCANNED Public Health x,15, <br /> Environmental 7-lit.:i it <br /> SRD-639R/R01/141 <br />