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County <br /> krvltl� <br /> 7' r.: Y Industry Services Division /� <br /> J° =;t::; . i�• 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 /,(• `3/y$1 <br /> State Transaction Number <br /> Sanitary Permit Application �— <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ,$�89.� J <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. �C 1''C✓SO✓� J�P <br /> I. Application Information-.Please Print All Information parcel# _ �,Iwlm D/-OOb <br /> Property Owner's Name p�. 18�� alf <br /> �-118�� -b/�000 <br /> moo f" ble w r�u v► <br /> Property Location <br /> Property Owner's Mailing Address <br /> ('01/0 d wA 4-e nJk Govt.Lot <br /> City,State Zip Code Phone Number y, V4, Section <br /> '9 (circle one) <br /> fG�G 1 N Ss"o, T 3 S N; P /b E ore <br /> II.Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> I or 2 Family Dwelling—Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number p Village of <br /> ❑State Owned—Describe Use Town of C C N tv H <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> RB, <br /> ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> New System El System P <br /> ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..C e of POWTS.S stem/Com onenUDevice: (Check all that apply) <br /> .-- ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil <br /> [XNo`_a Pressunzed In-Ground ❑ Pressurized In-Ground ❑ At _ <br /> ❑ Ii�Idma Tank El Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> V Dts I/Treatment Area Information: <br /> Design-H6*(gpd) esign Soil Application Rate(gpdsf) Dispersal Area D Required(so Dispersal Area Proposed(st) System Elevation <br /> �So s 9 an 166 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units wr 4jy <br /> New Tanks Existing Tanks — <br /> c U cn y cn cL C7 P. <br /> Septic or Holding Tank 0 U /000 <br /> Dosing Chamber- two `®O <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 iVIP/MPRS Number Business Phone Number <br /> c le o 14lei vs <br /> Plumber's Address(Street,City,State,Zip Code) <br /> wt W e bf y- fNy ft93 <br /> VIII.Court /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature _ <br /> 1 Approved ❑ Disapproved <br /> ❑ $ <br /> Owner Given Reason for Denial <br /> IX 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 8 1/2 s 1l in s i e <br /> umett0 <br /> aunty <br /> �Rn-F3n4 rRnl1�� d Land Services Department <br />