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' ��rr¢xyeti <br /> Industry Services Division County <br /> x, 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 <br /> P.O.Box 7302 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707 `h <br /> Sanitary Permit Application State Tran c on Number <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 Or different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> puroses acc <br /> p in ordance with the Privacy Law,s.15.04(1)(m),Slats. 26426 W Lipsett Lk Rd <br /> I,Application Information_Please Print All Information <br /> Property Owner's Name <br /> Michael Pandow Parcel# <br /> Property Owner's Mailing Address <br /> 070242391411505002011200 <br /> 1601 Tierney Dr Property Location <br /> City,State ZipCode Govt.Lot <br /> Waunakee, WI Phone Number <br /> 53597 V,, ,, Section 11 <br /> II.Type of Building(check all that apply) Lot# <br /> �✓I or 2 Family Dwelling-Number ofBedrooms 2 T 39 N R 14 E or W <br /> — Subdivision Name <br /> ablic/Commercial-Describe Use Block# <br /> State Owned-Describe Use 0ity of <br /> CSM Number illage of <br /> 2TO_of Rusk <br /> III.Type of POWTS Permit:(Cbeck either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> a licable. <br /> A. <br /> ❑New System replacement System ❑Other Modification to Existing System(explain) []Additional Pretreatment Unit(explain) <br /> B. <br /> ❑Holding Tank ❑In-Ground at-Grade Mound <br /> (conventional) Individual Site Design ✓Other Type(explain) <br /> c. eoMat <br /> Renewal Before Revision hange of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued Expiration <br /> IV.D' ersaU 1 reatment Area and Tank Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpd/sf) Dispersal Area R uired s <br /> 1.6 ( 0 Dispersal Ar^a Proposed(s1) System Elevation <br /> K 75 92-96 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units G <br /> New Tanks Existing Tanks V <br /> m <br /> .9 <br /> U o <br /> Septic or Holding Tank r; C7 ry <br /> 1000 1000 1 Wieser ✓ <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume reapo 1llty fo talia8o {the POWTS shown on the attached plans. a <br /> Plumber's Name(Print) Plumber's Signa <br /> Dan Burch �/MPRS Number Business Phone Number <br /> Plumber's Address Str Ci ty,State,Zip Code) r 253808 715.416.1642 <br /> ( �, <br /> N5921 County Hwy K Spooner WI 54801 <br /> V1.County/Departtnent 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 /> REVISED <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in size <br /> SBD-6398(R.02/22) <br />