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Coun <br /> r 'tir? <br /> -�r�=.`:�<-• „: Industry Services Division ,(�t�rn•C"� <br /> 1400 E Washington Ave Sanitary Permit Number(to be fille/d in/b� ) <br /> a ! P.O. Box 7162 <br /> Madison,WI 53707-7162 �l` 3 <br /> 1'g i"—y•.ep}r <br /> —.29 2 <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 Addres (if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary s'�74 <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. Application Information—Please Print All Information e�` (s C/C�? %3678 <br /> Property Owner's Name Parcel# y 6 .SS 'Y O'Y -0 o D <br /> l�OV? ef", rt a7^v.26�� <br /> o�d o00 <br /> Property Owner's Mailing Address Property Location <br /> 1/6 Govt.Lot <br /> City,State Zip Code Phone Number y x , <br /> aS� /<, Section <br /> /✓, /�o N, � $�/ (circle one <br /> I1.Type of Building(check all that apply) Lot# T y� N; R E or <br /> I or2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> B lock# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of 04/41-10 ad' <br /> II.1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ElPermit Renewal ElPermit Revision ElChange of Plumber ElPen-nit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV._T e.of PONVTS.S stem/Corn onent/Device: Check all that apply) <br /> E!`hioa ienzed In-Ground ❑Pressurized In-Ground ❑ At Grade krMound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ ffoldi' Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> .ems.. <br /> VSD s'Priam,al/Treatment Area Information: <br /> Desio Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> �►' � 7. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w [ u z <br /> a,U cn y k U G. <br /> Septic or Holding Tank <br /> Dosing Chamber_ lv /OOt. j 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,Signattuu�re MP/MPRS Number Business Phone Number <br /> /Z l e le /G t.,J �'t—�i�v� J�/ — ��3 6rs / 7/S- 800- � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776U y_ 73. we,ds7le "�Y— 5-1?,f <br /> VIII.Court /De artment Use Only <br /> El Approved ❑Disapproved Permit Fee p. Date Issued Issu' Age Signa <br /> ❑Owner Given Reason for Denial <br /> IX Conditions of Approval Reasons for Disapproval C f O 70 7 7 <br /> a�,s�ers�\ area. �er��:r�t k) 56(0 S(42s <br /> OCT - 1 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 ches in size ounty <br /> Land Services Department <br /> SBD-6398(R0313) <br />