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County
<br /> / , Safety and Buildings Division DA IJL-_
<br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary
<br /> ° Madison,WI 53707-7162 Permit Number(to be filled in by Co.)
<br /> ` • submitted online 3/17/2021 13-2021-00045
<br /> _ i
<br /> Sanitary Permit Application i State Transaction Number
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this torus 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 Sanies. Personal information you provide may be used for secondary w.of(shared/end of driveway with)8572
<br /> purposes in accordance with the Privacy Law,s.l5.04(l)(m),Stats.
<br /> L Application Information-Please Print All InformationI''',Ai-,:i ."-:la I I.A0
<br /> Property Owne,1's Name Parcel A
<br /> .1-f,-.140 i t,e..s..
<br /> i7AV I.-_ Cit.!i C i< 'T';1:-2'7- 034 eu;-10' 0
<br /> Property Owner's Mailing Address ' Property Location
<br /> ;.r.�:-I Lc,t<Il-C)-t L.l:i _ _ Govt.Lot
<br /> City,State Zip Code Phone Number f i,•\( , SE. V., Section .'1
<br /> ti Ci:210p I A , t,...i 1 ..:-A".9;<i 3 (circle one)
<br /> U.Type of Building(check all that apply)/ ``�� Lot# T N, R / LoFW
<br /> ❑I or 2 Family Dwelling-Number of'Berlroo /4 I
<br /> Subdivision Name
<br /> Bleck#
<br /> ❑Public/Commercial-Describe Use
<br /> U City of
<br /> 0 State Owned-Describe Usc CSM Number ❑Village of
<br /> QTownof _.("►'-lif( :I ALl_.
<br /> r),?/Ir i
<br /> DI.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A.
<br /> [(New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only l 0 Other Modification to Existing System(explain)
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground g At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) _
<br /> V.Dispersal/Treatment Arca Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arca Required(sf) Dispersal Arca Proposed(sf) System Elevation
<br /> t,-,c`C` c- t IL'>" Ic`cy% 41c;.tr;
<br /> VI.Tank Info Capacity in Total ft of Manufacturer O °o
<br /> I Gallons Gallons Units • as _ Y
<br /> U
<br /> New Tanks Existing Tanks 2 5• g .c Si
<br /> a.U in a as wU a.
<br /> Septic or(folding Talk I2a'
<br /> - l,?;-5. 1 frit.,r-. rC
<br /> Dosing Chamber 5,c--e."' L:',r- 1 1‘1C1-11)e, T`
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans.
<br /> Plumber's Name(Print) Plumber's Signature hGPIMPRS Number Business Phone Number
<br /> r"4rlt:'ty v> ►�t�'t 1-,1 N..,':T '1.. .1 ';*-T-e__ ,�' _ ..� •l[`IN�', :`
<br /> >I• ' }73
<br /> Plumber's Address
<br /> (Street,City,State,Zip Code) 1l j
<br /> ,.j;(• (-;V. t=1.> - `'Q.clt.t:lr`S..ice' c", b-._l T.7.,..59:1'/ ..
<br /> VIII.County/Department Use Only p ondliine cc 3/17/2021 •-. .
<br /> Permit Fee Date Issued Issuittg Agent Signature
<br /> Approved ❑Disapproved �/ _
<br /> $1,360 3-1 -Z- /'1�1 r�� 'i G-xs'«'�' .
<br /> 0 Owner Given Reason for Denial
<br /> IX.Conditions of Approval/Reasons for Disapproval 54.4 s -4,J( gez. <�-ry c,,e1,16�,r �,(oSe-/IOc.teu�s S.-
<br /> Y/
<br /> reg-T-427-4
<br /> Protect&Maintain: El Mound/N At-Grade site and 15 feet downslopein i natural V a Pc
<br /> condition. No compaction,excavation,disturbance,or vehicular traffic allowed.
<br /> 3 ci., -Zoe,/.
<br /> Attach to complete plans for the system and submit to the County only on paper not tan than 8 to s l I inches in size
<br /> ENSURE PROPER 1ANK(5)ALL-WEATHER SERVICE ACCESSIBILITY:
<br /> VERTICAL DISTANCE TANK(S)BOTTOM TO SERVICE PAD:<15 FT
<br /> HORIZONTAL DISTANCE TANK(S)TO SERVICE PAD:<150 FT
<br /> SBD-6398(R. I I/I I) Specific ServIcfnq Mechanics must be amvld.d if vertical is>15 ft/horizontal>150 ft
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