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�. lil61vCounty <br /> Industry Services Division l3k r„ e-1+ <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in <br /> by Co.) - <br /> �- - <br /> P.O. Box7162 - <br /> Madison, Ut/I 53707-7162 <br /> -till fY3 <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 govermnental 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 maybe used for secondary a�-9 S --1 <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. A licationlnformation-PleasePrintAllInformation ��YvSah f?C <br /> Property Owner's Name Parcel#0-7,01 <br /> J -d -b it'7 0 <br /> Property Owner's Mailing Address Property Location 'b3'� <br /> S 30a " Z, wVd v-e Govt.Lot _ <br /> City,State Zip Code Phone Number %, V4, Section <br /> S I 6e r M AlS3-0 7 y T N; R�� Sctrcle one) <br /> 13.'Type of Building(check all.that apply) Lot# /� E ory <br /> ❑ I or2Family Dwelling-Number ofBedroorns Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSMNumber r❑ Village of <br /> Town of iY11tih°t` <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement Systern ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain`) <br /> CaNnt64 4 v 4 Cf y(J E'l'1$71 S S <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 /> lV.,TYp,e,ofPoYVI'S..S stem/Com onent/Device: (Check all that apply) <br /> 0-N-ot Murized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑,K i[a p2.•Tha ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> VDs e sal/Treatment Area Information: ,. <br /> Des gn Tory(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 00 ex,s� boo <br /> V1.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a, o ,��, 2 <br /> New Tanks Existing Tanks w o Uu Y a 5 <br /> c,U �n m rn w C7 w <br /> Septic or Holding Tank <br /> Dosing Chamber ,S yo s-ao t t <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PO4YTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature bIP/MPRS Number Business Phone Number <br /> RI G le Av ln.f ��L.�.vC � ��J Q� 7�� <br /> Plumber's Address(Street,City,State,Zip Code) \ <br /> a776 a <br /> V11I.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fete Date Issue Issu' g Agent Signatur _ <br /> ❑Owner Given Reason for Denial $3 <br /> 1X.Conditions of Approval(Reasons for Disapproval <br /> Ktp,-} WJ Sx,+ba,_'& <br /> Fo Lt.ol.0 au cou,►ti S-Erg-k re t,, a v�w�,.-t+S v 13 2023 <br /> upda-fie co�nn,, e.n-}- mcLo kals -b Vus►avi 2. I <br /> I Burn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x I ces Department <br /> 36 <br /> SBD-6398 (RM 11) <br />