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_..-. � Coun <br /> Industry Services Division t^rrt e4 _ <br /> r if 1400 E Washington Ave Sanitary Permit Number to be}_rued in by Co.) <br /> R - <br /> `� P.O. Box 7162 <br /> Madison, WI 53 70 7-71 62 � <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 PO4VLuseEd <br /> submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may beor secondary -p 3 3 <br /> purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stats. <br /> 1. Application Information—Please Print All Information Co l2f� <br /> Property Own-*' **-- Parcel <br /> o�_o�a_a.tio_ <br /> •�'1eslk� o �I coo <br /> Property Owner's Mailing Address ll Property Location_ -Fmc I t> 5 3A5 <br /> d 0'-1 l /96bc l?A Govt.Lot <br /> City,State Zip Code Phone Number y, '/<, Section 17 <br /> Os1���skk W3 S'Y(5-0 (circle one <br /> H.Type of Building(check all that apply) Lot# T 4)0 N; R��E o / <br /> 1 or2 Family Dwelling—Number of Bedroorns ,3 Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial-Describe Use <br /> ❑ City of ` <br /> ❑State Owned—Describe Use CSM Number Village of <br /> ®Townof %)Awlcsom <br /> Iii.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .. <br /> ❑New System �T Replacement Systern ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Numberand Date Issued <br /> Before Expiration Owner l i v v <br /> IV.:t:�`e•of POWTS..Sr,tem/Com orient/Device: (Check all that apply) <br /> Noa h< razed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> EIS[am�.Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD:s''ersaI/Treatment Area Information: r <br /> Design'Fli+ri(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 45"0 S gory gov 9y L 9`�.G 9y. 4 <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E U II <br /> New Tanks ExisdngTanks o e a 5 <br /> L <br /> c,U in �, rn w C7 a, • <br /> i <br /> Sepdc or Holding Tank <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 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 0 , 3 — W-e5s7tl 57/ <br /> V111.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee I Date I)uuuJeddf Issuing Agent Si, Lure _ <br /> Owner Given Reason for Denial q <br /> 2 <br /> El � /i"�� <br /> IX Conditions of Approval/Reasons for Disapproval <br /> lftf k4loAdJ <br /> Ftllow tt (Cu -4y oid s-ia-k rq�lI✓�m�-''1fS JUN u 4 2 2�t <br /> a <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inche to slzLand Services Department <br /> 25 c,1v- i�51)0 <br />