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-e,4017:;q4,-. .. County <br /> = • '.;= Ii <br /> Industry Services Division i.c en,o <br /> r7=:•Et ,.) fr. 1400 E Washington Ave SanitaryPermit Number(to <br /> 4,s.•,�'.`r,.i•a +) be tilled tin <br /> Lby Co.) <br /> P.O. Box 7162 3 AN -c9a -3/ (A`f34 3 Z <br /> v„.. ,,,,,..,:: _,..4.,„, Madison, VVI 53707-7162 17, /l <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Win Adrn.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(l)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> �Momc.r'/I P 6n 07.611...1-NO'-if-/3-S/S-,i v <br /> -037,fo 0 <br /> Property Owner's Mailing Address Property Location <br /> 0/657/ //Aif ,1 e1 7r'R/- Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section /3 <br /> DA bury t/t 630 j,circle one) <br /> IL Type of Building(check all that apply) Lot# T y0 N; R / E or® <br /> jg l or 2 Family Dwelling-Number of Bedrooms 2 1 Subdivision Name , <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> V,ag ,/yy ®Town of J4 5 h <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System WRe lacement System <br /> 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS_System/Component/Device: (Check all that apply) <br /> iStNon Pre zed In-Ground 0 Pressurized In-Ground 0 At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ F{oIdm>Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V<D,ispersal/Treatment Area Information: _ <br /> Des igi PION✓(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> , i-C-40 , <S o0 goo 9/.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c3 o v 2 73 It 4 t8 <br /> c,U cn ti rn w C7 a. . <br /> Septic or Holding Tank io•ib0 /de?o / 1.,%1 C.P X <br /> Dosing Chamber- i .)I <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 MP/MPRS Number Business Phone Number <br /> j?/ #0?/Z-/ti f L7 C-4d / )02J8i l 7/5-8(x,6- 1//J-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 02 77 0 a y ' - '- (it/-,e.SS�rr 1 <br /> VIII.County/Department Use Only <br /> proved 0 Disapproved $ermit Feed Date Issued <br /> �] Is uiJ)g Age Signs <br /> 0 Owner Given Reason for Denial 105 Ll I 1 i P•a _/ / <br /> IX.Conditions of ApI�roval/iteasons or Disapproval „ . . E .„ . <br /> Otineex\-- <br /> . ) <br /> (_1 7/L x.25 <br /> fi <br /> AR 112022 JAttach to complete plans for the system and submit to the County only on paper not less than 8 I/3 x II ache in size <br /> My <br /> Land SQnvIoes Department <br /> SBD-6398(80313) <br />