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- County <br /> Safety and Buildings Division DAt.IE <br /> % 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 4s Madison, WI 53707-7162 <br /> `� • 13-2021-00145 <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 state•owned POP/TS 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(1)(m), Stats. <br /> I. Application Information -PleasePrintAllInformation VII-AS I-kit PO. <br /> Property Owner's Name Parcel # <br /> AMBES: ov RYAN ItLMMCQ di/ik- pH - .1125.0 <br /> Property Owner's Mailing Address P,op,.,ty Location <br /> '10'-f L1rvo.SA `( CT. Govt.Lot <br /> City,State Zip Code Phone Number S4 y,, SE- v.. Section 7 <br /> � <br /> __ r_ _ (circle one) <br /> l <br /> on-t- ALC F,fLr-VC t Wl -'�- `- 1 T 7 N: R II Eor-W <br /> II.Type of Building (check all that apply) Lot# <br /> Subdivision Name <br /> Q'(or 2 Family Dwelling-Number of Bedrooms I ` <br /> Block# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use _ _ M'Town of C aTA6C GI-aE. <br /> 'iiii34- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. El/New System 0 Replacement System 0 Treatment/folding Tank Replacement Only : 0 Other Modification to Existing System(explain) <br /> List Pmvious Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumbs ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> (4loo-Pressurized In-Ground 0 Pressurized In-Ground 0 AFGmde 0 Mound->24 in.of suitable soil 0 Mound<24 in. of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain)_ -- <br /> 0 Pretreatment Device(explain) <br /> V. Dispersalrreatment Area Information: DispersalArca Required(s0 I Dispersal Area Proposed(sf) I System Elevation <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) r�/��, � <br /> ;1CX) p.a+ 2250 2250 CCQUtV. 13. .>- 145 <br /> = S <br /> Capacity in Total 8 of Manufacturerer <br /> ` C y U <br /> VI.Tank Info Gallons Gallons Units a: U U -in m <br /> n <br /> 8 f <br /> New Turks Existing Tanks `' �ks in in ia. U W <br /> l <br /> Septic or Holding Ink -20x, — 7ean0 1 me-ace '� . <br /> Dosing Chamber it%Y_, _ ILm I ME1347C :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 MP/MPRS Number Business Phone Number <br /> NMI-CAA' l4 Me-64\CIL - �IV`----- `'4.'-- / -2 ‘2i lo> <br /> Plumber's Address(Street,City, State,Zip Code) <br /> VIII. County/Department Use Only <br /> ® ApprovedI ❑ Disapproved Parole FeeDam issued issuing Signature <br /> 5 464.00 06/02/2021 � �I�LiI ^' iICl/�JY'livLL <br /> 0 Owner Given Reason for Denial <br /> IX. Conditions of ApprovalfReasons for Disapproval <br /> - Attach to complete plat for the system and saloon m tae Canty only on paper not Mss rasa 8 ins Moans iocaer In size <br /> SBD-6398 (R. I1/1l) <br />