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County <br /> tYr <br /> r' Industry Services Division urn <br /> 4?` 11 1400 E Washington A( ve <br /> V S' 9 Sanitary Permit Number(to be filled in by Co.) <br /> P$ P.O. Box 7162 � � <br /> Madison,WI 53707-7162 <br /> ShIA <br /> Sanitary Permit Application State Transaction Number I <br /> In accordance with SPS 383.2 1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fors 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 ..735•-6 <br /> purposes in accordance with the PrivacyLaw,s.15.04(t)(m),Stats, /� <br /> I. Application Information-Please Print All Information /let Q(t N <br /> Property Owner's Name Parcel# <br /> 7� <br /> o?vde-d-NO-/!.-6N-3o3-osa <br /> M i&A -e/17e Br7d .e s - c.rY0oG <br /> Property Owner's Mailing.Address I <br /> Property Location <br /> IG 06 5- 74 St. Govt.Lot <br /> City,State Zip Code Phone Number _y, ao / Section <br /> 41 <br /> 44lele14% /YlA/ So43 f yrrc <br /> D N; R I lEon� <br /> It.Type of Building(check all that apply) Lot# <br /> ,K1 or 2 Family Dwelling-Number of Bedrooms 1:71, 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑Slate Owned-Describe Use CSM Number ❑ Village of <br /> V.177 P. 7p ff Town of 04t k!an 01 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> It. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plutnber ❑Peril Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Sys tem/Comonent/Device: (Check all that apply) <br /> 'kNon-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) I Design Soil Application Rate(gpdst) Dispersal.Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 30 0 yd 5 `/3d 9 v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o '� <br /> s U y <br /> New Tanks Existing Tanks Z <br /> Septic or Holding Tank 7.r- O <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(''Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> Plumber's Address(Sleet,City,State,Zip Code) <br /> 77(00 17/ 3'S' tti e6s?e (� S�7`87a <br /> VIII.County/Department Use Only <br /> Pe <br /> Approved C1 Disapproved <br /> ril Fee Date Issued �-• Issuing A t igna to <br /> ElOwner Given Reason for Denial $ J 7 f7b ?' 9q <br /> IX.Conditions of Approval/Reasons for Disapproval E C E 8 S E <br /> D <br /> ^�" � <br /> Attach to complete plans for the system and submit to the County only on paper not teJUN 2 4 201 <br /> ns than 8 Ill x inch 'o size <br /> 0 l —Z� 13URNETT COUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />