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- �'- : County (�
<br /> "y,-*1:41:T,+-, Safety and Buildings Division 11
<br /> �r �. i i t Y',
<br /> ' g Sanitary ermit Number(to be filled in by Co.
<br /> ill 201 W.Washington Ave.,P.O.Box 7162
<br /> r "° l} !"I Madison,WI 53707-7162 ry ( y )
<br /> #'��S r
<br /> SM�f�
<br /> Sanitary Permit Application State Transaction Number 1�y��
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit ! l -O ` (�P�+
<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 Servies. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stats.
<br /> L Application Information-Please Print All Information ctyl -)4'f b-ive ....0'_c,
<br /> Property Owner's Name Parcel#
<br /> m C:.:njO-3(-,2•-r?6-7)
<br /> Property Owner's Mailing Address 3 i '
<br /> Property Location
<br /> 472 l ' fort'etc,- f>_ Govt.Lot
<br /> City,State a Phone Number N A v., NU y., Section
<br /> f
<br /> Or (l�ta'1, Ovl T ■� hl R 10(circle
<br /> II.Type of Building(check a at ' .ply) Lot#
<br /> 91 or 2 Family Dwelling--Num.er of -. . . I 0" Subdivision Name
<br /> Block#
<br /> i ❑Public/Commercial-Describe Use
<br /> ❑City of
<br /> CSM Number ❑Village of
<br /> ❑State Owned-Describe Use
<br /> l4 �} / UTown of "•r'l 1 ...0".
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. CO New System / ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br />■
<br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued
<br /> g ❑Permit Transfer to New
<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 ti7 Mound>24 in.of suitable soll, ❑Mound<24 in.of suitable soil
<br /> 1 ❑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(st) Dispersal Area Proposed(sf) System Elevation
<br /> 4c.L - t# i.:' # -1r>r /✓t'6
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units
<br /> n & c v
<br /> V
<br /> New Tanks Existing Tanks U $Y u 13g `j v)
<br /> cn k.C7 al
<br /> Septic orHekiag Tank i r i?' _-- 11 x _' 1 l CA DE A'
<br /> Dosing Chamber i_ ;
<br /> _, u., l r1/4'11:71(>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 Signature y;,' IvfP/MPRS Number Business Phone Number
<br /> &YV AN kJ NVft`‘fry el. - i- ( I_ - C - 1,-._._� 2., f. .,� ,i .",-4,-,-
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> i, C it' V. 1 U\i't.41iilc.lt. , t,31 ',',;3 t
<br /> r
<br /> VIII.County/D epartment Use Only
<br /> Approved ❑Disapproved Permit Fee Date .sued Issuing Agent Signature
<br /> $ ii.
<br /> ❑Owner Given Reason for Denial - .3- 4-41* •
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> R�7es'r M*c'i' Tire .1g/ire ilIttrCe4 /S her- ,l 2'orsee,"F- /n' - AgittrieGoei.
<br /> eoNo/nda'• ,✓o Lon byweAr,✓, earts..Erving ?/spa€; a .r.,q
<br /> TeA FF1e M AcLOso s0 C.,^'.�L EI 16...S,' j
<br /> .
<br /> Attach to complete plans for the system and submit to the County only on paper not ess than 8 1/3 x 11 inches in size pu
<br /> G 22 ZOl7
<br /> SBD-6398(R.11/11) EI1VI Public Hearth MOr
<br /> SCAM ,' °nmentat i1(
<br /> ealth
<br /> s ii
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