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Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> _ Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> r P.O.Box 7162 <br /> Madison,WI 53707-7162 <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 NA <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. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> NISSA TUPPER 07-020-2-40-16-04-5 05-002-011000 <br /> Property Owner's Mailing Address Property Location <br /> 1696 JAMES ROAD Govt.Lot 2 <br /> City,State Zip Code Phone Number <br /> MENDOTA HEIGHTS, MN 55118 651 - 206 - 3282 . %, — 1/4, Section 04 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 E or W <br /> D1 or 2 Family Dwelling-Number ofBedrooms NA NA Subdivision Name <br /> Block# NA <br /> Lublic/Commercial-Describe Use <br /> NA aityof <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA IITawn of OAKLAND <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 <br /> applicable.) <br /> 17,71New System replacement System lather Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B' Ell-folding Tank IjIn-Ground [JAt-Grade Mound Ei Individual Site Design Other Type(explain) <br /> (conventional) PIT PRIVY <br /> C. Renewal Before Revision ❑Change of Plumber Transfer to New OwnerList 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 /> NA NA NA NA NA <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o o <br /> New Tanks Existing Tanks t c Y <br /> a U cn w C7 O. <br /> Septic or Holding Tank I I I 1 I II I - <br /> Dosing Chamber I I I = EJ <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> krlumt is Name(Print) OWNER: Plumber's Signature Business Phone Number <br /> NISSA TUPPER /4/U - 651 - 206 - 3282 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1696 JAMES ROAD, MENDOTA HEIGHTS, MN 55118 <br /> VI.County/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <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 in size <br /> SBD-6398(R.03/21) <br />