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County <br /> R <br /> Industry Services Division (�k P.0•e- <br /> , t ''-...r 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-716271 <br /> fYa; 97- al --2 2 g <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 <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 infonnation you provide may be used for secondary -71(� <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. Application Information—Please Print All Information S Je v l IS G 1 G Jr. v c1 <br /> Property Owner's Name Parcel# a S <br /> Nie,Ao% S 0aH- 013.41A <br /> Property Own—errs NtailingGAddress Property Location <br /> / j aka/w7 <br /> l G 1Y / Saf-1, .st N Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section _ <br /> /YI/l/ (circle one) <br /> 11.Type of Building(check all that apply) / Lot# T y0 N; R /6 E or J <br /> I or 2 Family Dwelling—Number of Bedrooms "7 Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> VT,.of O le1Ghv� <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Moditication to Existing System(explain) <br /> B. El. Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..T e.of POWTS.System/Component/Device: (Check all that apply) <br /> No fPreWzed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.ofsuitabie soil ❑ Mound<24 in.ofsuitable soil <br /> ❑�KgldmT Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VtDis ersa]/Treatment Area information: <br /> DesigsFlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) 5ystem Elevation <br /> Gad / 00 00 9y o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> y <br /> Gallons Gallons Units v U U ti y <br /> New Tanks Existing Tanks ,� o i E a 5 m <br /> a U In y cn u U a. <br /> Septic or Holding Tank / 5-0 ) � ��-e <br /> Dosing Chamber <br /> _ / j <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 ignatu Jl MP/MPRS Number Business Phone Number <br /> /Zi cl� f�o k,h _f ��z� f/ � 8.3—� 7/5--- <br /> Plumber's <br /> Address(Street,City,State,Zip Code) i <br /> �7 0 3 - w-�s�2'✓ �� S 7 ?�i <br /> Vill,Coun /De art ent Use Only <br /> Approved ❑ Disapproved Pen-nit <br /> Fee Date Issued Issuing Ag nt Signa <br /> ❑Owner Given Reason for Denial $��S I I l�I /;a <br /> I �Q Conditions o'Ap�ooval/I2easons r Disapproval r E ^ E a n n R <br /> 1 '�-C.'I' (`(vr" v <br /> a Nov Z 2 �r� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 is x 1l inc n <br /> 1LLBUM_etMtu_nty__J <br /> Land ServkM pepertment <br /> SBD-6393 (R0313) <br />