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=Industry <br /> County <br /> „4 Services Division /3�•r v�-e <br /> .�. 0 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> 10 <br /> PP.O. Box 7162rson, WI 53 70 7-71 62 <br /> 7 <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 information you provide maybe used for secondary .?itSd <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information S. Stior e Rd <br /> Property Owner's Name Parcel# $-O S— <br /> ��- ol ,s 3s- <br /> �,�d�n Pv Y0btW _ pl800n <br /> Property Owner's Mailing Address Property Location <br /> 17 I L1.S l L e v H l Ic 7— Govt.Lot S <br /> /<, Section <br /> City,State Zip Code Phone Number y <br /> L tt b i r'/P /VI A/ SS`O i/41 (circle one) <br /> 11.Type of Building(check all that apply) Lot# T �/O N; RL—E orP <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El Owned-Describe Use CSN[Number El Village of <br /> Town of �GC, 0 A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change o f Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV. pq.6f POWTS,S stem/Com onent(Device: (Check all that apply) <br /> 1X,,Non$Presst rized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil <br /> 011 KgldmTarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds ersal/Treatment Area Information: <br /> Desiga'Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> /SD , s goo &, 0 9 I.S` ry 9 s' s <br /> VI.'Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o o N .2 <br /> New Tanks Existing Tanks o v <br /> aU �n C/3 iC7 a <br /> Septic or Holding Tank G G 0 AMP <br /> Dosing Chamber- . Goo <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 Signature MP/MPRS Number Bus mess Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI11.Coun !De artment Use Only <br /> �pproved ❑ Disapproved Permit Fee Date Issued Is ins A nt Signatur <br /> ❑ Owner Given Reason for Denial $ {� P . fU <br /> IY.Conditions of proval/Reasons for Disapproval <br /> Ak. c-- ►n`6e� 5hee,+ comp. /y��nt��( FEENE <br /> (h2e� aN Se-�,`�t5 -t 5��- �e���►��''�' 0 3 2023Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 1l inchett Countyces Department <br /> SBD-6398(R0313) 7 '� � <br />