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County�u Ny)e 6�Industry Services Division <br /> , �i if 1400 E Washin ton.Ave - <br /> 9 Saniiary Permit Number(to be tilled in by Co) <br /> / <br /> fiI P.O. Box 7162' Madison, VI/1 53707-7162 <br /> t s 4.r/ <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 /> 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 information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),S tats. <br /> I. A licationInformation-Please Print All Information 3,5 <br /> nPro e Owner's Name Parcel# <br /> P <br /> o�_ado d-�ol6` _ tit aoo <br /> 1 �+ �� l�c,Vl+ t o <br /> Property Ow er s failing Address { Property Location _A ij X r`ftSs. <br /> 7 111 Ul1VG ?A �� ✓� Govt.Lot <br /> City,State Zip Code Phone Number y , <br /> s /<, Section Al� S.st LID (circle one) <br /> H.Type of Building(check all that apply) Lot# T y N; R /6 E o� <br /> ® 1 or Family Dwelling-Number of Bedrooms Subdivision Name <br /> B lock# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of ' <br /> ❑State Owned-Describe Use CSttvf Number p Village of <br /> V,e ? 3v J9 Town of �a��/G�✓i(,f! <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System p y p y Y (explain) <br /> ❑Replacement System ❑Treatment/Holding Tank Pe lacementOnl ❑Other to Existing System(ex lain <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.. `e.of POVy` 'S.S stem/Com onenbDevice: (Check all that apply) <br /> ❑`MlE f�essurized in-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Af Efa[.i--. ark ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds eUsal/Treatment Area Information: �. <br /> D69C Tlft(gpd) Design Soil Application Rate(apdsfl Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 <br /> VI.'Tank Info Capacity in Total Init <br /> Manufacturer <br /> 7J O V <br /> Gallons Gallons <br /> U - <br /> N.wTanks Existing Tanks o`/ �n cnSeptic or Hold ng Tank OoO ��� e-s-c-/ X <br /> Dosing Chamber_ t 3� <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/N1PRS Number Business Phone Number <br /> 410 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �}V,,III.Coun /De ar ent Use Only <br /> , Approved El Disapproved Permit Fee Date Issued Issuing Agent Signatur <br /> '\ El Owner Given Reason for Denial v15� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> J U N U 4 2024 <br /> rtko aU C ay, Vsf k KePi_WWY <br /> Attacb to complete plans for the system and submit to the County only an paper not less than 8 112 x 11 inche in siz <br /> Land Services Department <br /> �3�5 C)).e..I;k t5��j <br />