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Industry Services Division County
<br /> 1400 E Washington Avess.I(,. °3,44
<br /> ;;I s=i - P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.))'
<br /> `fit�_�% Madison,WI 53707-7162 4
<br /> State Transaction Number
<br /> Sanitary Permit Application
<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 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(1)(m),Stats.
<br /> L Application Information-Please Print All Information Pi-ttE, M19L't°i`11): P-J.
<br /> Property Owner's Name Parcel 8 ,1-5.54.-o
<br /> Property Owner's Mailing Address Property Location
<br /> ':::„ 2'r� -2
<br /> Govt.Lot
<br /> City,State I Zip Code Phone Number 1
<br /> htE % h Section 1
<br /> 1.41 Y1i A F'-i t-'Ii t 1:1]1 1 t'�4:..,- (circle one)
<br /> _. T 7 N; R�' E or=G'
<br /> IL Type of Building(check all that apply) Lot o
<br /> r 1 or 2 Family Dwelling-Number of Bedrooms -4- 1 Subdivision Name
<br /> Block 8 I ,� - 0 i).:64-e -Y�t,—.j
<br /> ❑PubliciCommercial-DescribeUse
<br /> ❑City of
<br /> ❑State Owned-Describe Use CSM Number ❑Village of
<br /> a r>d Town of � �
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' I W New System ❑Replacement System ❑Treatment-'Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br /> ' I I
<br /> B. I ❑Permit Renewal ❑Permit Revision I ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration 1 Owner
<br /> IV.Type of POWTS SystendComponent/Device: (Check all that apply)
<br /> i
<br /> ' ❑Non-Pressurized In-Ground ❑Pressurized In-Ground V)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) l Design Soil Application Rate(gpdsf) 1 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> VI.Tank Info 1 Capacity in Total I 8 of Manufacturer , I (
<br /> 1 : Gallons Gallons I Units ; o-g '
<br /> w `
<br /> New Tanks Existing Tanks ' c _ o _
<br /> ■ u in .. :n a tv a,
<br /> I Septic or Holding Tank 1G I I ! (t.,tPCE, X
<br /> Dosing Chamber 1 CaC — Ci•=v'7 ( 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 I-'MPIMPRS Number Business Phone Number
<br /> pbta4ztniW-N?44&Z. ',,._ L,t,- \.,--7,11 1,P.- lte5.3 71-1310-3
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> (-x"-,rj C-ht", 4-11,1..i,K 1,\41.41‘1.K.47 t 1,11 S j 7
<br /> VIII.County/Department Use Only
<br /> Permit Fee Date Issued 1 Issuing Agent Signature
<br /> ❑Approved ❑Disapproved �
<br /> 0 Owner Given Reason for Denial e: '' lOC/2Zj/p jj
<br /> IX.Conditions of ApprovaLReasons for Disapproval
<br /> ,P� T 4r-62464- SATE fND /tEt /s FEET DGYvirsLavE /N /n JvtJlGt4 lC, pJ/r,✓
<br /> t..)a eonMe riew, 0,srut¢lwfa✓ee; Etrl,}h.4$T w , oa ✓E/Y.tr4,4 C E I\
<br /> TQ Irh. is A1.Law66, - , t
<br /> Attach to complete plans for the system and submit to the County only on paper not less nun 81n n ii inches in st e p
<br /> JUN 1 ) LUI8
<br /> r'
<br /> SBD-6398(R.08/14) ..__._.._,.._,�- - v _ 4I 0 Cll T:CS Health
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