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„' ,:. 4±.v County <br /> `': ``„f Industry Services Division 13k y'yj.e1%-” <br /> gi;.:• t 4i;; „ ",. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,� •may: ....;._' 1 <br /> ? yi P.O. Box 7162 (o �43403 <br /> ',;.. !,•' '° .: r,4, Madison, WI 53707-7162 — '�2. <br /> � 7"› G51-2 a—ID <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SP5 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 PO ITS 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 GAS0 8''S. .Ff 6756 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information /4/'t'i /Zl <br /> Property Owner's Name Parcel# <br /> o�.. ot1,`d tic-13=io -S-!s"-i.ta" <br /> L,arv►y rl Ya h t9 73 0 o r� <br /> Property Owner's Mailing Address Property Location <br /> Pe /30X -767 Govt.Lot <br /> City,State Zip Code Phone Number / y,, Section /0 <br /> 5f- ‘ro/Y f.//f LAr SY.9ptLf 7/3=.lS4- ekit-0cl (circle one) <br /> II.Type of Building(check all that apply) Lot# T yO N; R /S' E oe9 <br /> Ili Ior2 Family Dwelling-Number ofBedrooms i 6q Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ig Town of Jac-lc-Job-7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. yo New System 0 Replacement System 0 Treatmendoldina Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ 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..:i'ype of POWTSSystem/Component/Device: (Check all that apply) <br /> on P siirized In-Ground 0 Pressurized In-Ground ❑ At:Grade 0 Mound>24 im of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Koldm3Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Des Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 4-1.S-0 . -7 G'/3 G.ro 9)• 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units n a '� o <br /> New Tanks Existing Tanks RI o v m ii8 <br /> c.U rn' y vl' u (J o. <br /> Septic or Holding Tank /0.r'0 /Of iJ ( J ,r llt,-i 71 or K <br /> Dosing Chamber- i .)t <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 // IvlIP/MPRS Number Business Phone Number <br /> �Z ftlp//Lin t /1�...-,4-K /' 4 QZ).c1,S-/ 7/5- ,f4G- Y/$-7 <br /> tGIG /- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77Go ,s��y �S titre 5s�`a S `y`S'97 - <br /> VI I.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fefe�nfJ Date[ssued 1 . <br /> suinpg�A��,e(nt Si�., ' <br /> ❑Owner Given Reason for Denial $ l'i 2' t/ ' 241 7I ? - Wl 147'--*7-` 33' ,f �„ <br /> 1� . v <br /> ft <br /> IX.Conditions Approyal/Reasons for Disappro i/ <br /> lc "r��` p,P'A� 4Oef ko�-Fcom boacVinc� 'ro r-U.ni� �' <br /> 1-an� ..o Aca►n k; e w;- 1�nçM-. f FEB 14 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than t/2 x II inches ounty--" <br /> Ca ennces Department <br /> Cam.* 6-11 ass *yas" <br /> SBD-6393 (R0313) <br />