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•'. .' Z=,,-� County <br /> f ,..; r+ Industry Services Division /3u►^n t r4' <br /> _a .�' 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> 4 •rsr' Madison, WI 53707-7162 <br /> �i ✓ <br /> 3 3 761$ <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 <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),Slats. /� �o y <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 3 g� �- /r 3 03 .060 <br /> Property Owner's Mail' g Address Property Location <br /> 939(0 /?d <br /> Govt.Lot <br /> City,State Zip Code Phone Number /, Y4, Section <br /> s�e r 151nfet 3 turtle one) <br /> I1.Type of Building(check all that apply) Lot# <br /> T 32 N; P /� Eor/* <br /> or Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 5rTownof Cslh <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Chan e of Plumber List Previous Permit Number and Date Issued <br /> g El Transfer to New <br /> Before Expiration Owner <br /> lv.Typ e.of POV✓I S.S stem/Component/Device: (Check all that apply) <br /> �`Non`Pressunzed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Haldin=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> aI/Treatment Area Information: <br /> Des gnFlo ti(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> q_f-0 . '7 (o 4Y 3 6 Y8' g3. Cl" <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks O " U u ' N <br /> a U � y C <br /> Septic or Holding Tank <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 JJ MP/MPRS Number Business Phone Number <br /> / <br /> /2/Lle /70 /,.► S T/ �, 8s 1 71-47 $116- 4115-7 <br /> Plumber's Address(Street City,State,Zip Code) <br /> 771(10 3J' �ivt h s>4✓ .wL -�7f 5 3 <br /> VIIl.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $3 2,5 <br /> ❑f.Conditions of Approval/Reasons for Disapproval <br /> off;6 <br /> 4� t�` JUN 17 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less t an 8 t/2 z It h,*W1rM1zj;ouniy <br /> Land Services Department <br /> SBD-6393(R0313) <br />