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2purposes <br /> ,x. county°43r Industry Services Division � k1400 E Washin ton.Ave 9 Sanitary Permit Number(to be tilled in.by Co.}P.O. Box7162�Aadisoh, V�/I 53707-7162' rs, State Transaction Number <br /> Sanitary Permit Applicationance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unitd prior to obtaining a sanitary permit. Note:Application forms For state-oavned POWTS are submitted to Projec[Address(if different than mailing address) <br /> ment of Safety and Professional Servies. Personal information you provide may be used for secondary 77S7in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. Application Information—Please Print All Information !`os <br /> Property Owner's Name Parcel#Ora L' 0 <br /> Property Owner's Mailing Address TI,1 Prope Location <br /> _79 b� GAIiC 4 61 Govt.Lot �ax �D �y�J7 <br /> City,State Zip Code Phone Number /, '/,, Section t7 <br /> 3 3 9 A c}rcle one),, <br /> II.'Type of Building(cheep all that apply) L Lot# <br /> R1 I or Family Dwelling—Number of Bedrooms o 5 Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned Describe Use CSM Number p Village of <br /> Town of Q a.IG 7G N 04 <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑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 Number and Date Issued <br /> Before Expiration Owner <br /> IV..i :"e.of P0W'Ti'S.S stem/Com onent/Device: (Check all that a 1 ) <br /> oii gs�urized in-Ground ❑Pressurized[a-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil. <br /> ❑ E[q[a1nTank El Other Dispersal Component(explain) El Pretreatment,Device(explain) <br /> '��;,:r_ <br /> VSDs`'esai/Treatment Area Information: <br /> Des gu Fto i(Qpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 30 . 7 413ot <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D o <br /> U <br /> New Tanks Existing Tanks o a <br /> a U m ti cn W C7 4 <br /> Septic or Holding Tank sV f v / 14/1,Cf 't v <br /> Dosing Chamber_ ! } <br /> V11.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5zigc7 <br /> Vill.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Pee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> cnd S rf_ttAi r-rW fs <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/a x 11 inches in size <br /> 4Rn_Aioe rRn2 1 2 <br />