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I <br /> , Safety and Buildings Division / in- A ill i <br /> itti 201 VV lW! nshington Ave P0.,Bo'< 7162 Sanitary Permit Piumbar(to S tilled in by Co.) <br /> ' '1/44..,-,Tilt �^) € 9 I : 2021 tiladlson,WI 53701-7162 , i <br /> a , / l�°�dtoo0 j <br /> `n\'?4 iv14N• '2, <br /> Score Transactlan Dfumbaf I <br /> Sanitary Permit Application <br /> s a Wis.Adm.Coda,submission arthis form to the appropriate governmental.unit <br /> (naq fired pri with obtPS aining <br /> I(-h <br /> is required prior to obtainingasanitar/ permit. Nota,Application forms for stataowned PO',VTS are submitted to Project Address liedifferent Wan mnllingad ressl I <br /> the Department of Safety and Proton ioaai Series. Personal Information you provide may be used for secondary �, i <br /> .0 ogee in accordance with the Prim Law,a, 1i K 11 ml,Scats. ji-te ai 1 <br /> �r■nn <br /> • I <br /> Property Owner's Name Parcel R 07 ( 7. - 3 x - clO(1l— t <br /> 'Qv"P ot- �t,.e.( sf' /"�RIU 'r" ' (adt'5 70:(ue'rSr?Fr Property Laotian 4, <br /> Newsy O net's Malang Address <br /> Govt,Lot <br /> /0 2 Osten. Phone Number c4Wl/+, Ai tv '/t, Seallon 3.3 <br /> Zip Cade (elmle one) <br /> 535-31 T -7 NI R/ 7- •BarW • t <br /> Qp ply) Lot If.Type or Building(check all that a ( Subdivision a I ar 2 Family Dwelling-Number ofBedcoams / t t <br /> Block✓k <br /> 0 Public/Comrneralal-DascdhaUse <br /> 0 Cltyoe <br /> CSM Number 0 Village <br /> ❑3tate0wred—OescrlbeUe PI"fawn of 4 <br /> '/-C/ <br /> I <br /> 1 <br /> i <br /> (a,Type of Permit: (Cheek only one box on line A. Complete line B If applicable) i <br /> 4" • QVern/3ystem 0 R.aplacement59stem ❑Treatment/Holding Tank aaptncementOnly aOther,rtadlEicationtoEditing System(axplain) k <br /> B. 0 permit&enewal 0 Permit Revision 0 change of Plumber 0 PemaltTr¢nsfer to New <br /> List Previous Permit Number and Oslo[baud ,€ <br /> Owner <br /> [Mine Expiration <br /> ry(V,T .a of POWTS S stem/Comp anent/Device: Check all that ar I <br /> 0:Non•Preaaurized fNQroand 0 Pressurized fn-Qround 0 At.Ocade 0 Mound 24 In,of suitable soil 0 Mound<24 in,of suitable soil 1 <br /> 'S0 HoldingTank 0Other DisperaalComponent(explain) 0 Pretreatment Device(explain) ( <br /> V, Dia.areal/Treatment Area informations stem Elev¢tion <br /> Design Plow(gpd) Design Sail Application Rate(gpdst) Dispersal Area Required(st) Dispersal Axe¢Praposed(at) Sy 9, 5 ) <br /> G 001 °/ /.S tea <br /> 4,510eR' 4 R e 3. ♦ t <br /> Total N of Manufacturer VI.Tank [nfo CGallonapaalty In a <br /> Gallons Gallons Units � 4 <br /> New tanks Escl¢tWgSacks ti awu IcnI aUlialigla , <br /> I l62&"G I tad( <br /> Dosing Chamber IIIIS■ ! 1 <br /> VII. Res p a as ib ility Statema tie, (,the undersigned,Mama responsibility for Installation of the POWTNshow nS on Nhe attached plans. <br /> Plumber's Name(Print) Plumber's Signature &cp22as09 608.849-877 L <br /> STEVEN a, CROSBY z�vivV <br /> n Pah l?!�r'P A ,�.�, �. cep <br /> Plumber's Address(Street,City,State,Zip Coda) <br /> 7161 DAMN DRIVE, DANE, WI 53529 <br /> z <br /> VIII. Count merartmeat Use Ont <br /> Permit Pee / Date Issued Issuing Agent Signator, <br /> Q Approved 0 Disapproved ll � <br /> 0 Owner Olsten Rama for Denial l k <br /> DC Conditions of Approval/Re/eons for Disapproval <br /> \ttwd:m a,mplaae plans inr nm quoin '^tl ,nhmi<m the Cnvnry nn Ll+n Oapm nor km nun 1 u'. t LI Indio In lin: <br />