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,, ' ;., Industry Services Division County <br /> rcit U 1400 E Washington Ave �1�� <br /> 1=1 :.;S '=' P.O.Box 7162 <br /> p Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI53707-7162 5����,��"�. /r// q h, 'J7...:,,aid '��""JJ �'T tP g�U <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(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(1)(m),Stats. /// /I. Application Information—Please Print All Information 12t81 I r-IiJC Iq / <br /> Property Owner's Name / Parcel# <br /> av,`ol A,%/eje... Oh,74t.z-1?/-e/-s o5'-c67- ce5706 <br /> Property Owner's Mailing Address Property Location <br /> I3ye 1-/INf/N /r/�kwy ��. <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> 14 % �, <br /> , Section <br /> f q 6A) SV g 5I Z�j circle one) <br /> II.Type of uildingapply) T 7J N; R lg E o� <br /> }p (check all that a ly Lot# <br /> 1-1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block At <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 1//O3 '`Z6 2/7 Town of 1 c �L� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / !� <br /> A. <br /> 0 New System 64 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) J <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Holding Tank 0 Other Dispersal Component(explain) 0 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 /> y7) <br /> VI.Tank Info Capacity in Total T of Manufacturer <br /> Gallons Gallons Units u o <br /> New Tanks Existing Tanks V <br /> U <br /> El <br /> c V in TA m iz O a, <br /> Scptic or Holding Tank 5000 7e / �i, �, K <br /> Dosing Chamber (�� <br /> VII.Responsibility Statement-, the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl041'9 1,744, <br /> us cr's Name(Print) Plumber's n ree/; MP/MPRS Number Business Phone Number <br /> / - -62.4 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6Se Am-Ai Ile %/ ( e 6 4 vi- 5'09, <br /> VIII.County/Department Use Only <br /> ItApprovcd 0 Disapproved Permit Fee 0 e Date Issued Iss ' g Age Signatur <br /> 0 Owner Given Reason for Denial S 3 75 7/5/i ) <br /> -' � <br /> IXM.Conditions�gf Approva easons Disapproval <br /> eV— <br /> a ��731, . EIJVIETh <br /> ato i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 s 11 recto is s L " T 2022 J. <br /> t <br /> Bu men Courtly i <br /> Land Services 4 • <br /> SBD-6398(R.08/14) - D�:p2rrtrrr�rrt <br />