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�yIn37`p 1i <br /> ;y �• Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI53707-7162 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel <br /> Property Owner's Mailing Address Property Location <br /> Z 2 6 3 Govt.Lot Z <br /> City,2'a, <br /> Zip Code Phone Number y, % Section Z <br /> s� r�/f�3 T rcleon <br /> dr vv N, R Q E o <br /> II.Type of Building(check all that apply) Lot# <br /> 1�I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> Town ofr1A L Lk- <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g El Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply)❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 0r r� <br /> Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /7/��'("'/1 / D 3co 7L q` <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks w = y y `u y y <br /> ` C i y p 4 C3 <br /> a V in y rn i.L C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POVI'TS shown on the attached plans. <br /> Pi u er's Name(Print) Plum gnaturc MP/MPRS Number Business Phone Number <br /> T llQ �/ «5z/ /�-S6�-azoz <br /> Plumber's Address(Street,City,State,Zip Code) <br /> kle i�,/e, U.- _5Xy6g <br /> VIII.Coun /De artment Use Only <br /> ❑Approved ❑ Disapproved S Permit�� 8Date Issued qV Sign <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CCE9YE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 insili Isize <br /> AUG 19 2021 <br /> SBD-6398(R.08114) Bumett County <br /> Land Services Department <br />