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County <br /> : : r4 Industry Services Division 9UL r n.c-ff <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <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 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 d Q9 y q <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. (uS <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> GL4LIV'%L 1"a�h;� aG Lemke L[,G a�-o3d-d-yJ- S-dG� <br /> 14,48 o�S"oao <br /> Property Owner's Mailing Address Property Location <br /> /q��s-/V. 1. ed 13k d r.rw, ( Govt.Lot —.�— <br /> City,State Zip Code Phone Number %, '/,, Section <br /> 1�L1 G 11 Ah N /"S /—r 9 l O 7 circle one) <br /> T �� N; R 4� E or4 <br /> Ill.Type of Building(check all that apply) y Lot# <br /> PSI Ior2FamilyDwelling—NumberofBedrootns ( Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use El city of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> Town of fw11f <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' R New System <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Pen-nit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> mlype,of POWTS.S stem/Component/Device: (Check all that apply) <br /> (Nag Ore razed In-Ground ❑Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,ofsuitable soil. <br /> ❑ Haldtn=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dts 'eisal/Treatment Area Information: <br /> Des%n to ti(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevationoa . 7 �S7 Feo I w-9 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units lu46 <br /> New Tanks Existing Tanks c -u U <br /> o <br /> a U v, A cL C7 a. <br /> Septic or Holding Tank d 6 d S�fO O <br /> Dosing Chamber- <br /> / ' .t <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 l/ MP/MPRS Number Business Phone Number <br /> 12/G14 fro' /4/" S ��T� ,�,58.5-i �,5,f`6-y/s7 <br /> Plumber's Address(Street,City,State,Zip Code) --�i <br /> 77 liO /7/wt <br /> VIII.Court /De artme t Use Onl <br /> Approved ❑ Disapproved Pennit Fee Date <br /> to Issued Is en ignature <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 in x It inches in size <br /> SBD-6393(R0313) <br />