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%'i,A1!..f.:i',..... Industry Services Division County <br /> 4- �'''. 1400E Washington Ave DO Di-14 <br /> 1;j∎_ • 1 P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ` ` r i Madison,WI 53707-7162 <br /> ./4:; / 5 Jute ck10 3`f <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(lxm),Stats. <br /> L Application Information-Please Print All Information t_Llrt'lit nil T4-1,-`>:. <br /> Property Owner's Name Parcel# <br /> -FIT-- I hUP:1fW Ivi-S 11-1- ...D 7r)(-1)- 321',-F I V(i: 0 <br /> Property Owner's Mailing Address Property Location <br /> 710,' E l i _',� --1---,L. Govt.Lot <br /> City,State Zip Code Phone Number `7.7)v..J y, V C. ,/, Section 'J <br /> M le N r-\, 1n1 t _`-;mac,t,,2-_' (circle one) <br /> D.Type of Building(check all that apply) Lot# T 7 N; R E orb# <br /> ©f1 or 2 Family Dwelling-Number of Bedrooms °I.- c� Subdivision Name <br /> Block# Pr-,1�,A I'. CriC'.J El_"*U1e`. <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of M telLI(eft t <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 Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <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 5Mound>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 /> Y. ,14- fe:_. Y7) 1/85 _ i o--+ i' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units , 5 v$ <br /> New Tanks Existing Tanks c u h 4 e <br /> a U in i m it-1 a <br /> Septic es.l eldieg Tank i Z`r> — i2':,k f M E�*i _ x <br /> Dosing Chamber ,c,�,- — L-E ` I MC-lra _ <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 lvtP/MPRS Number Business Phone Number <br /> ill-sol r.w vii It'le'I 1 h Li 1- .--A--t--- L"-- . .2C'l C..1 -. t-3 <br /> _ �,_. frr 7 2, <br /> Plumber's Address(Street,City,State,Zip Code) .� <br /> t›. '( C CAA\"hi -4-KNii. V.yt Li.,,a L.', , V.i t C17-3C:-.) r'' <br /> VIII. ounty/Department use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing ignature <br /> $ - i� iwl <br /> ❑Owner Given Reason for Denial (�Z/Z3//� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ihor ir" Houu/vp siac- 4N0 died+ /S peer- -/vuarF 1,t, in' NQ-Iu�?t ,C.tr•ti p /rlB+t/ <br /> IVO C444114oT/6 Ali p/S7wRd!""G6i d, fv4tr/oyf/ d/L. ✓AP-h/e4444+e <br /> Vial PPiG -/S 44.Laki,do. t i c, , ;s; <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1r1 it 11 inches In size <br /> • <br /> SCANNED <br /> SBD-6398(R.08/14) <br />