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-,,,i '27;d ;f. County <br /> g `t Industry Services Division jLA✓n e,tt— <br /> t� 1 . R - 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> �'1 P.O. Box 7162 <br /> j S -23 -87 <br /> ,.. ".. Madison, WI 53707-7162 (5o97� <br /> * „'%� GSl-2?S -&) <br /> State Transaction Number <br /> Sanitary Permit Application <br /> [n 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 /D c.i 8 I <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information JZ ed A 11 '2 /✓t i <br /> Property Owner's Name Parcel# 4 a 1 7-3 D_s-/y_ '.,5=,s <br /> 31 w. Corn i 5 4 Ai07- c736—J' p). Woo ,J <br /> Property Owner's Mailing Address/ Property Location 44,2 7 5/`T <br /> I-1 7 5 /}Sh to r, Cu r ve <br /> Govt.Lot <br /> City,State Zip Code Phone Number t , <br /> /, /+, Section 3 0 <br /> a t.Gl b 444,7 M N .5-57,,g ((c��trcle one <br /> IL Type of Building(check all that apply) Lot# <br /> T 4/0 N; R / ) E o <br /> 24 I or 2 Family Dwelling-Number of Bedrooms 3 / / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number p Village of <br /> ti Town of t4Nle/1 <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> • <br /> A. New System <br /> y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ElPermit Revision ❑Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration = Owner - <br /> IV..Type of POWISSystem/Component/Device: (Check all that apply) <br /> 10,-lNbti-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Ko[aunTTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> DesignTIN/(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> YS0 _ , 7 G If 3 6s-e, , 8 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'� o <br /> New Tanks Existing Tanks ° c u E u _a ccaa <br /> 0 <br /> c.U cn y ii U P. <br /> Septic or Holding Tank ID GO /elf 0 J 4211J ;Alyg.)4py <br /> Dosing Chamber- ) :}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 MP/MPRS Number Business Phone Number <br /> /?/c/c L Ioow s /2 h._J 1/4,a krSSi 74J-- cFGt- y-/r7 <br /> Plumber's Address(Str et,City,State,Zip Code) <br /> ,7 ..? ' W-e.4.s1r, " sza'53 • <br /> VIII.County_/Department Use Only . <br /> OApproved ❑ Disapproved Permit Fee Date IssuedI g gen ature <br /> 0 Owner Given Reason for Denial $ L a5 61`3 I <br /> IX.Conditions of Approval/Rf asons for Disapproval <br /> 14l2ek 11 ---� ja c1-j t �4-G '(Gr'jt e4 <br /> Celltijzojec • ✓11a11(Act/ 5k JUN 13 2023 J <br /> J <br /> Rurnett CoH'y r <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 irches i2 d Services Department I <br /> -iy26 -*5035'-1 <br />