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Industry Services Division County <br /> ,� i y <br /> �� � �•;t�, 1400 E Washington Ave <br /> �.N S P P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI5370'4162 t <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(2),1Vis.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-owncd POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m,Slats. <br /> ?. Application Information-Please Print All Information 36cego <br /> Property Owner's Name // Parcel# <br /> a CK �� 07-d -Z- -Z�Z oZ-oaD-o rlt3oo <br /> Property Owner's Mailing Address Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, Y4 Section <br /> 61t?N4�0P t y rcle <br /> E f,W J <br /> II.Type of BuildingT N, <br /> (check all that apply) Lot# R o� <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block g <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Z Woe 1016 To rn of_ We-;i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. r� <br /> lNew System ❑ Replacement System ❑Treatment/Holding Tank 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 O%%mer <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> INon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound-e 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(gpdsf) Dispersal Area Required(sf? Dispersal Area Proposed(sf) System Elevation <br /> 3C� t 9Zy viz 9z5 92-z. <br /> VI.Tank Info Capacity in Total :of Manufacturer <br /> Gallons Gallons Units ' E o' g, R <br /> New Tanks Existing Tanks a <br /> a V in y rn rz v 0. <br /> Septic or Holding Tani: O <br /> Dosing Chamber W <br /> I I ' I ++ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for lastallation of the POWTS shown on the attached plans. <br /> Plu er's Na1-04 me(Pont)/ Plumber's cure_ MP/MPRS Number Business Phone Number <br /> drjpli / � �q J�� 7/�-'S —DZD'Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 8 v o,/7-ry Wel (Vebt4er V,. <br /> 9114 <br /> VIII.Couny/Department Use Only <br /> Approved ❑Disapproved Perrmit Flee DL.a�te Issued^ Issuing Agent Signature <br /> ❑Owner Given Reason for Denial S 1�J� ( rd GlJ2y <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 12�a,� ��zs <br /> �b tow o U C�1+V and S-1-u4 r e q�.i rewt�.r 4F =V l� ` fi� <br /> Attach to complete plans for the system and submit to the County only on paper not less than g trl x 11111 It sFtc <br /> APR 0 2 20224 <br /> Burnett <br /> SBD-6398(R.08114) Land Services Department <br />