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,--c"A-6,, County <br /> Department of Safety <br /> & Professional Services, <br /> _ p Ex -Ili Industry Services Division Sanitary Permit Number(to be filled in by Co.) <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 rl c'ay( on i,r .c.kc i 1.p� <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 0� <br /> I.Application Information-Please Print All Information O ''o y ) WI 5 4%3 O <br /> Pr��rty Owner's Name Parcel# <br /> 10141 liked\\er /gl23 <br /> Property Owner's Mailing Address Property Location <br /> N 3 5s o G70*� 5-(1 Govt.Lot /S <br /> City,State Zip Code Phone Number <br /> Ellswo(-Fh Vi1 51-loI1 7/5-3o7-a9447 v., 1/4, Section 6-63 <br /> II.Type of Building(check all that apply) Lot# g T 1� N R I11 E oie <br /> ❑ 1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 117 City of \ 0.Y1 UY'_ <br /> ❑State Owned-Describe Use CSM Number 0 Village of 51 Town of ./4' <br /> 74 <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. ❑ New System <br /> y ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. )(HoldingTank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design <br /> gn ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner <br /> List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o n <br /> New Tanks Existing Tanks d e a) Q <br /> aG in a v wC7 a. <br /> Septic or Holding Tank -. WIZ" aSO I Skn� <br /> Dosing Chamber '7 <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ture MP/MPRS Number Business Phone Number <br /> Altt)KiJ D 21,,E /337 3 7fc Sat sgo0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 60 c1 j7S 570tGc e//5eve;►4 t r w/ 5-yo i f <br /> VI.County/Department Use Only <br /> ❑ Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> S <br /> 0 Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval 4- <br /> r- - �n eo11'l lic‹�%d� E © ll V 1 <br /> x floi-e PP D <br /> 1¢- ei,edx 4- p-pp,bacK it i/ap JUN C 9 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches...Stcblurnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />