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County n <br /> r Industry Services Division 14 rh d ' <br /> 1400 E Washington Ave - <br /> _ 9 Sanitary Permit Number(to be tilled.irr.by Co) <br /> P.O. Box 7162 _ <br /> ' Madison, WI 53707-7162 <br /> J.ss <br /> Sanitary Permit Application State TransactronNumber <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 PO4VCS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infonnation you provide maybe used for secondary $'�/8 fj <br /> purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stats. <br /> I. Application Viformation—Please Print All Information Ae—btrey LAt• <br /> Property Owner's Name Parcel# <br /> a7_ o3b-�-yd-17-13 -S- Gad <br /> Property Owner's Mailing Address ,f Property Location—,0.x `b.Z�h�-7 <br /> 6 i r <br /> -7 J in I A O 0 /7 v ' Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section 3 <br /> -SU l�l —y 61 (o -77 (c'cle one) <br /> T �67 N; REor� <br /> 11.Type of Building(check all that apply) Lot it . <br /> I or Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSMNumber p Village of <br /> 0-Town of U 0 1 C h <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of PIumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 3s, y 15�/9 88 <br /> IV..i e.of POWTS..Sys tem/Corn orient/Device: 'Check all that apply) <br /> Vrq RYed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ E[a[atl�Taiik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VrD1s esaI/Treatment Area Information: " r <br /> Des g"M-v(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) ' <br /> Dispers Area Proposed(st) System Elevation <br /> 300 . 5- ov f Q 0 96 v <br /> VI. Tank Info Capacity in Total #of Manufacturer <br /> p u U <br /> Gallons Gallons Units ,o � :: _ <br /> New Tanks Existing Tanks <br /> 4� Q, U y •cd <br /> c.U �n ti cn w U P <br /> Septic or if. <br /> Tank <br /> DosingCliamber- <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> 4. <br /> Plumber's Address(Sere t,City,State,Zip Code) <br /> )77 U wT S-zIS53 <br /> VIII.Coun IDe artment The Only <br /> Permit Fee Date Issued Issuing Agent Sign e <br /> 9Approved ❑Disapproved S /'-�� 2 <br /> ❑Owner Given Reason for Denial y <br /> IX.Conditions of Approval/Reasons for;Disapproval D <br /> 11���� G.(.� i r��,h'U.s't�s <br /> low cut- (may Md f Ye1 Gc APR 19 2024 <br /> EX'S- 6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/3 x 11 in hes in size Urnett ounty <br /> Land Services Department <br /> SBD-fi194 (Rn�131 't�LI 25 l�� ���u� <br />