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— , hdnWySwvI=DWWcm County <br /> 4822 Madison Ytmds Way (V l <br /> Mattison,WI 53705 =T-3 <br /> Number(t o be filled in by Ox) <br /> P.O.Box 7162 _ 23 D <br /> Ma�On,WI 53707-7162 �a _ (c5�pwo <br /> Sanitary Permit Application State Transaction Number <br /> In aocordsoce with SPS 383.21(21 Wis.Aden Code,a tni on of tars foam to the appnopiate pvernmemal unit <br /> is required prar to obtaminga mduay pwrA Note:Apeman ibrms for swnv�awwf POWTS are wba►itted to Project Address(if NO dm mailing ) <br /> the Npa I iiaxu of sa8ety and Profissional Swvims.Pet:c and itiffirmstion You provide my be used for secondivy J ,/ <br /> in aocomiance wkb the PnvW Law,a 15: i)(ml Sys. <br /> L AppOextion I>sSwawden—PkewfWat AN labrmadea <br /> Property Owner's Name Pmeel# 3 U 5 01 <br /> IUD ti T�� 35yCs5� <br /> Owner'sftolkly Mailing Addivis r Location <br /> , Godc w <br /> City,state Zip Code Phsone Nsunber <br /> V 1 s� .��i ' .. .SedansL.L, <br /> MTypeof (e6edtahtl6atawiy) h.a* T 3 R <br /> al or2 Family Dwelling—NumberofBe600ms subdivisan ° <br /> ittCQmnsaeisl—TksenbeUsie CAN\PG�(;1� Block# <br /> 'tyof <br /> Owned—DownibeUse CSM Nnmber iltyeof <br /> awn of N1F N <br /> III Type efPOWTS Pesasift(C6edc slier"New"er"RepaeencsY'and after applidt6le*aft*A. C6eBc ear bu to bursa IL Cease a litre C i <br /> AM <br /> smm sy:�m her Modifoudon tomatins system(explarILndiv-.,idua0l <br /> Pr�tmentunit(evasia) <br /> 8` Tank Obt,Grcnusd QAt-Grade OmmwSite Des�i Type(eP�) <br /> C. Reoeai Bewe ❑R tuitionFI ofRu naw ❑rMsftuNewmmit Numbar and Date brAd <br /> iIV. i+ss�sesat Arta add Tads Inkrmefion: <br /> Design Flow(slid) Dow Soil Application RdaUp/s� Disperse{Ares Required(at) I�w <br /> Propawd(at} I'! <br /> f t—m vevation <br /> Capacity in Tamil #of hbandidurer <br /> Tank Infommtion Gallons Call= Units a <br /> AtsreTa� ExWn%T=b y <br /> 8epge or iioidira Tea , <br /> »ice tf5o F-9 I=IR <br /> V. Stttft armt:-&dw iWWM%ft4 atsaroe rasimat fsr• of fte POWTS sdiewa ea fteadedw4 platen <br /> M mobWs Now(Ptita) 's Si Basirims Phorse Nimtber <br /> Plumber sAaaress(Shm City,saa,zit Code) <br /> vl.Cog. tUaeoa <br /> M Appmved 0 Di ,ed permit Fee Daee 8 <br /> 0OvmwGi,�R t DenialS 425piD l D�l� 2U23 ` <br /> Conti of ApptuvsMeasons for Di: vat <br /> 00 Ow s-AA -s C CCU [ 0 M CE <br /> I la-� r.l.l Cr�,t�tfy a� S-�ct� reL(-�,' rt,r�c�,,•✓t+s D <br /> 0 C T 18 2023 <br /> wetad.aa. ep�ear>re. .wwr.rratre..�r.r�esp ..tte &W8 it indmuLdwit County <br /> Land Services Department <br /> SBD-6399(R.03/21) 299 S pp <br />