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j<sI zTu.'Ay.., industry Services Division County <br /> , i,` Xi\ 1400 F.Washington Ave DA PAF_ <br /> IV <br /> � , 1. - P.O.Box 7162 Sanitary Perr,>tt Number ito be tilled in by Co.) <br /> +- _ /�, Madison,WI 53707-7162 <br /> ��'_7;,w,,; - 13-2021-00163 <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 slate-owned POWTS are submitted to Project Address(if diiftbrcnt 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(ixm),Stats_ <br /> I. Application Information-Please Print All Information thr-x:tCEt) V 1 t.. .-r:.r "i tz N I L <br /> Property Owner's Name Parcel# <br /> TCDD kAT4-112Nt .1 CI-IR-I TE1•.L .--3,4 rri't l -ICI-x(76-0 <br /> Property Owner's Mailing Address Property Location <br /> FA i cl R tis-(1c_ V-4 A 1( Govt-lot <br /> City.State . Ltp C'ttdc Phony Number 141-4 tifr. NE ''/, Section 1 e0 <br /> I\Ac VIM-4 Ar--i O, ("A t F.7.72).Fe> 7 ' R It(circle ) <br /> II.Type of Building(check an that apply) Lot k T <br /> ®'1 or 2 Famiiy Dwelling-Number of Bedrooms tr p Subdivision Name <br /> Block' 14-t=e4*U[OON I..iILLS <br /> 0 Public`Commercial-Describe Use <br /> — 0 City of <br /> 0 State Owned-Describe Use CSM Number Village of <br /> ri/Tovaof 6C11 1�-E 6 ftC''UE <br /> IILType of Pierian: (Check only one box on line A. Complete line B if applicable) <br /> A_ IiNew System 0 Replacement svtear. 0 Treatment' Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> Femur Revision 0 Change of Plumber fist Previous l'rrmtt Number and Date issued <br /> R. D Permit Renewal ❑Pe <br /> ❑Pcmtit Trsn:frr to New t <br /> Before Expiration i Owner <br /> IVT.Tv pc of PO ATS System Component/Device: ((;heck all that apply) _ <br /> Ei Non-Pre;cururd In-Ground 1]Preeauriml In-Crround 0 At-Grine ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreiutnent Drvice(explain) <br /> V.Dispersal:'Trcatment Arca information: <br /> Design Flow tgpdi Design Soil Application Rarergpdsfl Dispersal Area Required(en Dispersal Area Proposed(ci) I System Elevation <br /> ?50 fi),l-} Ifin S 1S1i.,-. 1.5' ` 619,` <br /> l7.Tank Info Capacity in Total 4o Manufacturer <br /> Gallons Gallons Units .. f t-t <br /> St.;Tars Existiog Tanks g Pl ' 1 x <br /> a <br /> r.t :n Ti to -C: a- <br /> Septic orHolding Tank its. — Itccn j 10e Ate A. <br /> Dosing Chamber <br /> `Ti.Responsibility Statement- I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Same(Print) Plumber's Signature M.P.'MPRS Number Business Phone Number <br /> AYIel tzv\ Nle-.1'v hej...,:-+-_-1_,_ L.-3 '--."-'- . t k„.....--r) C.CAG-Pig I'SI <br /> Plumber's Address(Stmt.City.Cr/ Statet�Zip Code) <br /> G.,,=2,1?" Cr/ '-f-) i 'Aixt,uylk.>^: WI 5.3F/17 <br /> VIII.County/Department Use Only <br /> E Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature � <br /> Owner0 Given Reason for Denial s 440.00 6/10/2021 / / <br /> LX.Conditions of Approval'Reasons for Disapproval <br /> L <br /> Attach to compete plans for the system and submit to the County only on paper not less than 5 121 11 tache to sift <br /> SBD-6398(R.08/14) <br /> 4 <br />