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County nn <br /> • • Industry Services Division !7�✓Y�?i <br /> pq �n --- ----- -- <br /> - ' tF See R�Y 1S1O 1400 E Washington.Ave Sanitary Y4-'l <br /> Nmber(to be filled in-by Co) _ <br /> _ AN- oq <br /> P.O. Box 7162 <br /> Madison, VVI 53707-7162 <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 may be used for secondary 3 D 09 11 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / ,l <br /> I, Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0-7 <br /> ce.IVt 000 <br /> Property Owner's Mailing Adc1ress Property Location <br /> �s Lw�ct/k�o� ��,,,,;1 -Fa)(-Fa)( 1p 22"lg"1 <br /> 3oa <br /> G <br /> City,State Zip Code Phone Number Y4, Section d 7 <br /> (circle one <br /> Il.Type of Building(check all that apply) Lot# <br /> N; R��Eor� <br /> 1 or2 Family Dwelling—Number of Bedrooms Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> tEl StateOwned—Describe UseCSM Number ,Sw I Jj <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV..r e.of POWTS.. stem/Com onent(Device: (Check all that a 1 ) <br /> LNoah MFized In-Grourid ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> E [alrr 'i! ElOther Dispersal Component(explain) ElPretreatment Device(explain) <br /> D s"e saI/Treatment Area Information: <br /> Des gn?Ftoty(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 5i). S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o N New Tanks Existing Tanks 2 o u � di 2 v is <br /> c U m y cn w C7 G. <br /> z <br /> Septic or Holding Tank <br /> Dosing Chamber_ <br /> VII.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on!thettached plans. <br /> Plumber's Name(Print) Plumbers Signature MP/MPRS er Business Phone Number <br /> 7/J:: <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77Ge .3s t Li e <br /> V""Coua /lie artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date issued Issu g Agent Signature _ <br /> ❑Owner Given Reason for Denial I l Z5� 1 (11312024 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ptt Vj a+441S JMAY 3 0 2024 <br /> k1l ow aU cep +y amd E4ak ref r irrerKen-� <br /> Burnett <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tl?x 1l in bes it (I SerVlCes Department <br /> CRn <zno mn,i,� <br />