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`�wrsr�ay Industry Services Division County j <br /> /�� 1400 E Washington Ave Lane, 1. � <br /> ' ' c P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �;� .,:r).-:., Madison,WI 53707-7162 <br /> il„ 9, . 3 .d—r:/t— Ccc t <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(1Xm),Stets. <br /> L Application Information-Please Print All Information St Ivertril Qoad <br /> Property Owner's Name Parcel# <br /> MREC VIA 't 0708'0.05/6r5'oeA <br /> Property Owner's Mailing Address Property Location <br /> (ct3dl SL'1,t-fR't I-owe, 1)- Govt.Lot <br /> City,State Zip Code Phone Number SE- y., SW y., Section 490 <br /> Well'r (Nil 113 T 7 N; R g (circle once) <br /> U.Type of Building(check all that apply( Lot# <br /> gr1 or 2 Family Dwelling-Number of B-. 128 Subdivision Name <br /> Block# St: ufe 4-601:31J Re_p(Af- 150.1 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> WPown of M jdc(Ieti'1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 27New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> 13. ❑Permit Renewal ❑Permit Revision ❑Changes of Plumber ❑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 /> El/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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1S0 . 4 Ie,I5 l8go .43.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0 <br /> New Tanks Existing Tanks 1 0,U 'rim a a wt7 a <br /> Septic or Holding Tank Itoe0 — IL�a I I•AEAC <br /> Dosing Chamber -- I MeP 'C _ <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 /MPRS Number Business Phone Number <br /> Poneirt M W. Me„*t Z .■(-- ley.. 011'5 831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> CeAS Cexmty -k4 IL V■kluhw(ee,bst S3 5q' <br /> VIII. ounty/Departmeat Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Si <br /> $ <br /> ❑Owner Given Reason for Denial ` 3 i ' Z % <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D. <br /> k. <br /> i N,Attach to complete plans for the system and submit to the County only on paper not less than 81/3 x 11 Inches In size <br /> I c' 3 Y0i8 <br /> SCANNED <br /> Envi oriiflent<il ew2alth <br /> SBD-6398(R.08/14) <br />