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„ e; <br /> / f,v County <br /> /r '"�'•: Industry Services Division 13cArn <br /> ;. i' at, 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ;s � t ` 1 P.O. Box 7162 5A1J-e20-86 <br /> ' Madison, VVI 53707-7162 <br /> 2:4..; ` CSS_ <br /> -;2�— <br /> Sanitary Permit Application State Trans/action Nuzmb�er�i <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 043' f/-I • <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 A 9 yp if <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information Al x01,4 n /Z al .iNA,_1 <br /> Property Owner's Name Parcel# 41- Nd-16- <br /> O 6-.r-is” <br /> p7-e'Av- <br /> 6'co aid R a det al-r Gbb- 0130" <br /> Property Owner's Mailing Address Property Location <br /> 3 ti`-(6 W,((iw 8 ', t► re( Sw <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 6 <br /> it <br /> (�r 10✓' li/e- mN S--(-3 7( (circle one <br /> II.Type of Building(check all that apply) Lot# T 410 N; R 16 E or(V <br /> R I or2 Family Dwelling-Number of Bedrooms 3 3 Subdivision Name <br /> Block 4 <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> ® Toavn of O .l4 fe of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System S <br /> y �Replacement pacement y stem <br /> ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber <br /> El 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 /> .tiir tion Pressurized In-Ground ❑ Pressurized(n-Ground ❑ At:Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in of suitable soil <br /> ❑-EIolding:Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispers'al/Treatment Area Information: _ <br /> Design��gpg <br /> d) Design Soil Application Rate( pdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> . 7 6 y3 6 9g 5d-3 ✓ <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units U Y ti o <br /> New Tanks Existing Tanks , o u6 Y ca cd <br /> a.U m i C/34. u C. <br /> Septic or Holding Tank /000 /000 j f/Lat^, X <br /> Dosing Chamber.. j .)., <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 /> Ric% /`Aloka k f�;� � <br /> -�- tu /447v4L• a d(5-5: l -vs:, x'61-1//57 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> al 776 o /A,-y 15 W-€6.s 4r' L✓3— ,5-2/r,3 <br /> VIII.County/Department Use Only <br /> — <br /> Approved ❑ Disapproved Permit Fee Daa�te sue suing Agent Si,, lure <br /> .4", <br /> ❑ Owner Given Reason for Denial $3f 5 ✓ 2 'Z��'� <br /> Y an <br /> IX.Conditions of Approval/Reasons for Disapproval r• Mak <br /> 4 <br /> -"StrkkAA . ieUe.i4.01‘ 'Katt- be. of oe &loan. 92.30 ft E © G 0 V C <br /> •-ord sgsfdAc 46 be a ou doiieed per firs 3a3, D <br /> -'_1i ?AVOCA OSUA l sb%cte $ts 21 of bedebb 4S SN S WA. wl ifi be. Mai k„ I 1i i 111 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ins it in,11in e <br /> / :urnett County <br /> SBD-6398(R0313) Land Services Department <br />