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` x ��.. Cltat7 <br /> f� -'- Industry Services Division k <br /> 1400 E Washington Ave Sani mber(to be_tilled in by Co.) <br /> P.O. Box 7162_ Q 4 L' <br /> Madison, WI 53707-7162 dr7N ? <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 PO4VTS are submitted to Project Address(if different$an plailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary / Gt <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# 3s-- S— d S <br /> - <br /> .)v� GA ho V, <br /> Property Owner's Mailing Address p Property Location <br /> 4 LJr,d, ,c �d Govt.Lot r <br /> City,State Zip Code Phone Number y, '/a, Section 3S~ <br /> G / crr <br /> O cle one <br /> 1I.Type of Building(check all that apply) Lot# T N; R E or <br /> l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Corwmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number >❑ Village of <br /> Town of JG,6/GSorn <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑Treatment/Holding Tank Re lacement Onl ❑Other Modification to Existing System(explain) <br /> New System ❑Replacement System p y p <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Hefore Expiration Owner <br /> IV..C e.of ROW'I'S..S stem/Com onent/Device: (Check all that apply) <br /> Non:- a zed In-Ground ❑Pressurized[a-Ground ❑ At-Grade _ <br /> F--- •x.�•, ❑ Mound 24 in.ofsuitabie soil Mound<24 in.of suitable soil <br /> ❑Kaldtn Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD:s=I/Treatment Area Information: <br /> Des gu7R (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area),,,poed(,Ilstem Elevation <br /> yS0 (,43 6s'o �j 1.o 9a• D <br /> VI.Wank Info Capacity in Total #of ManufacturerGallons Gallons Units U <br /> New Tanks ExisdngTanks cnSeptic or Holding Tank /O6t7 x <br /> Dosing Chamber_ } -�� • <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 / MP/MPRS Number Business Phone Number r <br /> /?I G �is <br /> Plumber's Address(Street,City,State,^Zip Code)�776-e, <br /> VIII.-County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signa e _ <br /> Approved El � I f-�_/50 -71I t, 2mVLq <br /> El Owner Given Reason for Denial <br /> a <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 1 s llb� on Z <br /> Attach to complete pla s for the syst and shbmit to Elie County onty on paper not less than 8 t!?s 1l in hes"'Effhd Services Depart[tlellt <br /> 4Rn-Fine rani t i) <br />