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County <br /> /, - Industry Services Division /3tr vo0 t-tY- <br /> ;`4•i,. 0. .4 1400 E Washington Ave Sanitary Permit Number to be tilled in by <br /> Co.) <br /> SP ? P.O. Box 7162 ��p-7r /,4 <br /> 1N _S j Madison,WI 53707-7162 O `TG�aa•• I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(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 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats, <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Wi 1fwA,J 07- 018-d-ti0 -/y-mS-S /3"-576 <br /> - a9ouoo <br /> Property Owner's Mailing Address Property Location <br /> J6("J CI..ic 'R1eX c.rt S Govt.Lot <br /> City,State Zip Code Phone Number /,, Section S- <br /> L✓at t It e s ti R w I S3 Is 9 a 4,4- ?8 9- dd 840 (circle one) <br /> II.Type of Building(check all that apply) Lot# T 'YO N; R /'f E o&7 <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms_ _ 1-7 Subdivision Name <br /> Block# <br /> ❑Public/Cotmnercial-Describe Use Le <br /> ❑ City of <br /> ❑ CSM Number El Village of <br /> State Owned-Describe Use _ p <br /> V. /� f Q Town of Xe a 7Y- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System y ❑Replacement System ®TreahnenUHokling Tank Replacement Only El Other Modification to Existing System(explain) <br /> l;• ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Permit Renewal El Revision <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) JJJ <br /> Q Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable s <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 00 1 — -- — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a a u o <br /> New Tanks Existing Tanks •'O U d `v ` ' <br /> Septic or Holding Tank /O." <br /> Dosing Chamber Sa./O Sy0 1 <br /> VII-Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature,(/ M9P/MPRS Number Business Phone Number <br /> e-le <br /> f�o /c/�r t �Z.,.�-..� �`� AdJ` f1S/ ?/S-l�iG—�//$-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77G0 -/ 3.fw-e6s/ e <br /> III.CountylDenartment Use Only <br /> Approved 11 Disapproved �I] <br /> Permit Fee Date Issued Issuing g t Sign ure <br /> $ <br /> 11Z76'Owner Given Reason for Denial , — � <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a in c 11 inches in size <br /> SBD-6398(R0313) <br />