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r .irr4,%, County <br /> ;,+r Industry Services Division ! " <br /> s q 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> �SPs.. � P.O. Box 7162 <br /> `eyrxf/ Madison,WI 53707-7162 k%V <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 govermnen[al unit Of!/f/ / q/ <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 / <br /> purposes in accordance with the Privacy Law,s.15.040)(m),Stats. 4 6�Ys /7d <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 6-7-CAO-d,Yo.,t��33-d- <br /> 13f Wotf<vo Pre . LAG ( 13pM d �tr _ C,3 33060 <br /> Property Owner's Mailing Address Property Location <br /> 3igf w• Webb Ole- vr. Govt.Lot I <br /> City,State Zip Code Phone Number y,, %, Section 33 <br /> Lvtbb G fG (cvcleone) <br /> U.Type of Building(check all that apply) J Lot g T �P D N; R f4 H oro <br /> ❑ <br /> ,y <br /> I ort Family Dwelling-Nuntberof Bedrooms Subdivision Name 1LL^1J <br /> �j J� � Block# -5ab. -f Devis I r/Y <br /> Public/Commercial-Describe Use (J R /► �, �. <br /> 3 <br /> El city of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> _P]own of ©a 0/L/n <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y ❑ Replacement System ❑ Treatmem'Hnlding'Cank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ 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 PON'TS S stemlCom onent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Arca Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° a <br /> New Tanks Existing Tanks o v y A <br /> Septic or Holding Tank 3 Q® <br /> I.t77toSz✓ ><1 <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 /> le/L/G 17leao lCin <br /> Plumber's Address(Street,City,State,Zip Code) <br /> D 10K� 3S kV-eba/-e Gv—" S S`B53 <br /> V111.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing.Ag gnature <br /> $ <br /> El7c� 23 Ila,Zal <br /> Owner Given Reason for Denial ✓ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D E EIVEnn <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 xin size <br /> nJUN <br /> 17 2015 <br /> SBD-6398(R0313) SURNETT COUNTY <br /> ZONING <br />