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\. <br /> -e.g l e i".‘. Coun �1._ <br /> / •,•,-• ter+ Industry Services Division /j' rn-e7� <br /> 14:.:. , <br /> , , 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.], <br /> `z,; .; ;:.' r'1 P.O. Box 7162 et-I O CO 2 ff <br /> .,,..r: ' ,, Madison, WI 53707-7162 <br /> State Transaction Number <br /> - <br /> Sanitary Pet mit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govenunental 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 d 4/it 0 P4 r.4 µ n Rd- <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. Application Information-Please Print All Information 114$75 <br /> Property Owner's Name Parcel <br /> a cp} d G- -5t0 1 G p6S S <br /> ! ".Oal7oo0 <br /> /Gtn qt- 6e.e5 f7a//rn O <br /> Property Owner's Mailing Address Property Location <br /> 13 773 PIC✓'f'e t.(1 e S-f- N w <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section 6 <br /> / d 0 v•t✓' Ali N 53-301/ (circle on <br /> II.Type of Building(check all that apply) Lot# T Yd N; R /b E o <br /> 0 I or 2 Family Dwelling-Number of Bedrooms d Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use • <br /> ❑ City of <br /> ❑State Owned-Describe Use CSIvI Number ❑ Village of <br /> kl Town of d4/4-(4vve• <br /> M.Type of Permit: (Check drily one box on line A. Complete line B if applicable) <br /> A. 'New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Moditication to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner - <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> Aisto-ii2triE-411-12-ed rn-Ground 0 Pressurized In-Ground 0 At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ F{dldm=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSDisper al/Treatment Area Information: <br /> Des io FIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> ?6 0 7 //'' <br /> VI.Tank Info Capacity 7� ySO �j,l.f 5, d, 93. 3 <br /> p ty in Total #of Manufacturer y <br /> Gallons Gallons Units o - o <br /> New Tanks Existing Tanks 4° U e id cv �� <br /> c.0 cn va u.0 IL <br /> Septic or Holding Tank fee Re / J`/e A w Y <br /> Dosing Chamber- . _ ; )t <br /> VU.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 /> /Z, e/e //01.0 le to f /?e. 1 li/ ./cArg_S`/ 7 43- e4 6 • y 45—/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J7760 W'y .7 ov•rds'rr k✓�. 'c5 Y - <br /> VIII.CountyiDepartment Use Only <br /> 0 Approved ❑ Disapproved <br /> Permit Fee M Date Issued I su' ent Si tut <br /> ❑ Owner Given Reason for Denial $ 5 <br /> 101 -1 I t -', r P 1 V/ C <br /> - <br /> IX.Conditions of Approval/Reasons for Disapproval / L— <br /> PP � CK <br /> Auzo�C7 <br /> SEP 2 1 2021 zij . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 itches in size ;urne County <br /> Land Services Department <br /> SBD-6398(R0313) <br />