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County, - <br /> T� `n. . Industry Services Division L4VY1 <br /> ftt` 71' See Re isl n 1400 E Washington Ave - Sanita ry Permit Number(to be_t_filled in Co.) <br /> n �^ <br /> P.O. Box 7162 <br /> Madison, V�/I 53707-7162 ` <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate goveroanental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms For state-owned POb rTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. ! �(� <br /> I. Application Information—Please Print All Information ��"'` 7-CLY. <br /> I'Z�jrj9 <br /> Property Owner's Name Parcel# 36- SOS 003 <br /> h Hot Y /l om-,W L4l[t llBrnl S �7-ot$-�� _ o!S"000 <br /> Property Owner's NI filing Address Property Location <br /> "?3) /,s f 11 vL /VW Govt.Lot .3 <br /> City,State �^ Zip Code Phone Number y, %, Section 36 <br /> /7 h .aV t(— M/V J 530 1^f (circle one <br /> II.Type of Building(check all that apply) Lot# T 3� N; R /6 E o4 <br /> I or Family Dwelling—Number of Bedrooms W Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use v 917 JE17city❑State Owned—Describe Use CSMNumber of <br /> ® Town of Mecnon <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New ❑S stem y Replacement System ❑Treatment/Holdingrn Tank ReplaceentOnly ❑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..T' `e.of POWTS.S stem/Com onent/17evice: (Check all that apply) <br /> ❑Tina Pie razed In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> a.. — <br /> = 4 ai <br /> €io[am?Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD s e sal/Treatment Area Information: <br /> Design FtoFr(gpd) Design Soil Application Rate(gpd4 Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks o <br /> o 2 a <br /> n U m ti cn w 0 P <br /> Septic or Holding Tank ldS� 7s-a -e <br /> Dosing Chamber_ } �i <br /> V$1.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the PO1V TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R �h le,ki s <br /> Plurnber's Address(Street,City,State,Zip Code) <br /> 7 XW Zwz 41" _1_ � <br /> Viii.County/Department Use Only <br /> Approved ❑ Disapproved Pen-nit Feed Da e Issue�dJ� Issuing Agent Sig ature _ <br /> ❑ Owner Given Reason for Denial " 124 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> r tu-, W-t ccunM M1 S+tLA-e AUG. 2 3 2024 !f <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 11 inch s in si e <br /> t hand Services Departure^s <br /> CRrI_�Zn4 rono i i� <br />