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O <br /> b�✓Hl Yr <br /> far. ,•� Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ` 1 P.O. Box 7162 -a�— <br /> iw.': •;:. Madison, WI 53707-7162 <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 POWTS are submitted to Project Address(if different than mailing address) <br /> •. <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary &$7 <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. F l p w a l e a Y( V e <br /> I. Application Information-Please Print All Information Parcel# <br /> Property Owner's Name o7ra3)-) yt- <br /> r�i omo3SG <br /> Fj-p.rt t 4 G h o o h C S a <br /> Property Location <br /> Property Owner's Mailing Address <br /> 7476 fj p e H A d tyG Govt.Lot <br /> City,State Zip Code Phone Number / y,, Section <br /> _ (circle one) <br /> Ce L' G✓p v� I��l� .S S D 1 ro T N; R _Eor(�J <br /> II.Type ft Building(check all that apply) Lot# <br /> Subdivision Name <br /> t 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 fw Ild <br /> III.Type of Permit: (Check only one box.on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ElPermit Renewal ❑Permit Revision ElChange of Plumber JE1 Permit Transfer to New , <br /> Before Expiration Owner <br /> IV.f e of POWTS.S stem/Com onent/Device: (Check all that apply)Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑.C{3ldm�Taiik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds ersal/Treatment Area Information: <br /> DestgnT16*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) =Areaion �s;3 VI.'Tank Info Capacity in Total #of ManufacturerGallons Gallons UnitsNew Tanks Existing Tanks <br /> c,U rn y � w C7 ❑- <br /> Septic or Holding Tank V 4 99 y 6 0 X '—n F' j,,A I-1,1✓ k <br /> Dosing Chamber.. <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 NIPMIPRS Number Business Phone Number <br /> Plumber's Address(Street ity,State,Zip Code) v <br /> d 7,'b D /Y(- j�5` tom✓-4 5 S 74Y­ <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date[sued issuing Agen Signature _. <br /> Approved El Disapproved 7��� `/ Z, <br /> El Owner Given Reason for Denial ' 3 <br /> I.C.Conditions of Approval/Reasons for Disapproval <br /> D <br /> E0E0YE <br /> I. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2. I i es in size <br /> urnett County <br /> S R D-F l ns r R 011 31 L Land Services Department <br />