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Industry Services Division County
<br /> 75-/''''?,7-7-... ..‘ • 1400 E Washington Ave Nre
<br /> 4.7-.. vr\
<br /> ,..,N.
<br /> , ,... ,_ P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> l,', N..,. , ',.,' Madison,WI 53707-7162
<br /> :2) j — '. C,C01(
<br /> 1"."-----_--
<br /> Sanitary Permit Application State Transaction Number
<br /> In accordance with SPS 38321(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 stzte-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,a.15.04(1Xm),Seats.
<br /> L Application Information-Please Print All Information ,'-x..,■ i r404-f- l'-'
<br /> Property Owner's Name Parcel#
<br /> Vey icl I An tic-tyler., A-,Lt.C- () 7.-- ')-()1.,2-22',--.',- -C.:.
<br /> Property Owner's Mailing Address Property Location
<br /> •
<br /> 4.),.. Govc Lot
<br /> City,State Zip Code Phone Number 4‘.1 k.,-.) y., N l".} V.,Section Cr>
<br /> Mic.,1((.4•4 , I...31 r.r.),i,3 (circle one)
<br /> T i N. R F E oe.SW
<br /> II.Type of Building(check all that apply) Lot#
<br /> V:1 or 2 Family Dwelling-Number of Bedroo..
<br /> .1,,,i
<br /> Block# Subdivision Name
<br /> r;r1V brei.ls' \kJ 4% ■
<br /> i
<br /> 0 Public/Commercial-Describe Use i
<br /> 0 City of
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use
<br /> ra'Town of M i 714
<br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 24Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) I Design Soil Application Rate(gpds0 Dispersal Area Required(sr) Dispersal Area Proposed(sf) System Elevation
<br /> • t;. l2'..4.-.1 1,4 10
<br /> VI.Tank Info Capacity in • Total #of Manufacturer
<br /> Gallons Gallons Units .,e. „E 7, .2
<br /> New Tanks Existing Tanks ` u -i g !.., 2 1.3 a
<br /> tel.) iT)0 m il:0 a.
<br /> Septic or Holding Tank ,va,(x , — , IE Art
<br /> Dosing Chamber _
<br /> . I A(LA,'1,-,
<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 be/MPRS Number Business Phone Number
<br /> ( -, /
<br /> 4._, -7- /
<br /> Plumber's Address(Street,City,State,Zip Code) ./
<br /> g Cc-u , i 1,\ir IA,let K.,-.,-•• 1/,.1 :: :4 7
<br /> VIII County/Depirtment Use Only
<br /> ,ZApproved 0 Disapproved Permit Fee Date Issued Iusustgature Agent '
<br /> 1 .,,,,
<br /> 0 Owner Given Reason for Denial //3//LP // he.---
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> Patrer" ,1001.45 / & 406-f /s- fr—eer Apw4isevioe- ,A., /rs. le...FiriZot. -e-s.v.0/1W'V.
<br /> A/C) C4'ne'vnmi D' re-14134.4,ee: eve44.•41a0.4i, •■ i/e-/f24ej_4( 7A1PP74 /3 '' --
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la z 11 Inches in size
<br /> 'SCANNED
<br /> SBD-6398(R.08/14) .
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