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gCounty <br /> rNW <br /> f s Safety and Buildings Division �ccr <br /> i+1 201 W.Washington Ave., P.O. Box 7162 <br /> a , $P rl Madison,9 WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Sanitary Permit Application StatcecTr�ansacc/tion Num <br /> ber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (ff4 t� 40'a .) <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 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 /> L Application Information-Please Print All Information Jr <br /> Property Owner's Name Parcel# <br /> �� •; -nnq man C�#3S v-ozy2- •f�-o3-S ofoD -oi <br /> Property Owner's Mailing Address Pro art Location <br /> RO. Box 9/62 P Y <br /> 14 EA `le L.A-Yl& Rxhafsr„(/,y ,55 a3 caul Lnt 3 <br /> City,State Zip Code Phone Number y,, Y., Section „3 <br /> Opt�(L �2 54gbl 5C,7- 2 le one) <br /> II.Type of Building(check all that apply) Lot is T 3 l N; R Fit <br /> JO I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use _ <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number ❑ Village of <br /> r V /�a�2 ua G L 3 ® 'Town of Li!4_9 <br /> Ill.Type of Permit: (Check only one box online A. Complete line B if applicable) oa - <br /> A ❑ New System Y Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑ Permit Revision ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onenUDevice: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑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) Design Sail Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> �iSO . 2 a <br /> VI.Tank Info Capacity in Manufacturer <br /> Gallons oNew Tvtks Existing Tanks os VeUSaprieor Holding Tank /Dosing Chamber <br /> VII. Responsibility Statement- 1,the unJersigne assume responsibi' for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI tier's gnature MP/MPRs Number Business Phone Number <br /> M&K SEPTIC & EXCAVATI <br /> Plumber' a , <br /> SPOONER, WI 5480 <br /> 1/11 Count /De r e <br /> Approved ❑ Disapproved P ��Permit Fee Date Issued Issuing a ignature <br /> 2 / <br /> ❑ Owner Given Reason for Denial 3 (�f N2 Z6/L <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> SW, s�r gkPt.;lt lank, is not uwt-fwa {ha, lane. A6 FllooRQlatn of 60V r 6� <br /> EIc �4t: Vo✓rb��ri t'S}M <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ill a ILPtilf in <br /> SBD-6398(R. II/II) SURWE7-rCO tG <br /> NG U! <br /> ZON <br />