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Count <br /> y <br /> 7sr,, Industry Services Division 1,11.4.rn <br /> T0':',...: „ Sanitary (to be tilled in by Co.) <br /> f ` �. 1400 E Washington Ave �Slanity Permit Number <br /> 1+ : ;4' .; y ri P.O. Box 7162 Sp-NI-22-1 6 <br /> v4 .k` l Madison, WI 53707-7162 l(,8D" <br /> „ rx. <br /> Sanitary Petiint Application State Transaction Number <br /> • <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 Servies. Personal information you provide may be used for secondary 77 y 6 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / l'? / <br /> I. Application Information-Please Print All Information (�1' P?�n f O� <br /> Property Owner's Name Parcel# <br /> Nei ( Carlhe� a7-e3d-a`y I../6-3o g'000- Boa <br /> Property Owner's Mailing Address Property Location <br /> 4 95'8 G../-h St !vE Govt.Lot _ <br /> City,State Zip Code Phone Number %, /, Section .3) <br /> CO/a►m b l4 N i r J /v)14/ .57p-1 I ircle one) <br /> II.Type of Building(check all that apply) Lot# T �� N; R /6 E o>� <br /> fg 1 or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of .Sk✓/.T5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. (fi New System <br /> y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other N[oditication to Existing System(explain) <br /> • <br /> B. 0 Permit Renewal ❑Permit Revision ❑ 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) <br /> •56.Non Pres u ized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>_24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ EfgldmgTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Daapersal/Treatment Area Information: <br /> DesigrTldw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> NSO . 7 GY3 GYg 9at.. d . <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units n t o B <br /> New Tanks Existing Tanks o 2 a 5 <br /> c.U cn' ,,, rn u-C i a. <br /> Septic or Holding Tank /Z.d 0 7040 / PfrirPSz'i Y • <br /> Dosing Chamber_ / •), <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 /> 2/Z.k-- Na d/C/N r / -� /�„�.. S`ZrS/ 7s ea- ///5-.7 <br /> Plumber's Address(Stree,City,State,Zip Code) 1 <br /> . 77 0�� 33" �ir'c�s/�� S 93 <br /> VII .County/Department Use Only <br /> Kr- <br /> Approved ❑ Disapproved �Pennit Fee 09 Date Issued uing ent Si, <br /> ❑ Owner Given Reason for Denial 5 6/61 <br /> IX.Conditions of A proval/R asons�Or Disapproval <br /> yWee4- Ail Seti s , <br /> JUN332022 J <br /> A. <br /> Attach to complete plans for the system and submit to the County only on paper ant less t)rpn t/a 8 x 11 inc�Orn COUnty <br /> f Land Services Department <br /> SBD-6398(R0313) <br />