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';x,;i..; Department of Safety County ., <br /> • On -Ne <br /> ',_a: & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> re Industry Services Division 5R-;\)-25- F <br /> ,, C5—a5---2 Z7 (o 0c <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adin.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application fonns for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be 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 <br /> Property Owner's Name Parcel#�1�,�.Li -i 5-,_l I-r a.r <br /> C.,7- L <br /> 0,,„i i ol. I-7 v, A/.t 10 II - O el-- ©Itv CVO <br /> Property Owner's Mailing Address Property Location �aX- p 52�� <br /> l g l 1 ( A MI fc 11 t t`r Pei <br /> Govt.Lot 7 <br /> City,State Zip Code Phone Number <br /> Y, ' , Section // <br /> II.Type of Building(check all that apply) Lot# 3 T 90 N R /� E 61 <br /> cit 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> U , 1 a ? P7 gTown of J6tc k-ht ✓i <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A' ❑New System XReplacement System ❑ Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank ❑ In-Ground ❑ At-Grade El Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Change ❑ Transfer to New Owner List Previous Permit Number and DJ2o1L' <br /> to Issued <br /> ❑ Revision of Plumber <br /> Expiration UN-I(p -I,5 9 I1 1 <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 70o t 1 9a,1 t.,©0 901 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 2 ° u <br /> U m <br /> New Tanks Existing Tanks d 6-'0 °3 T, 1 <br /> ta <br /> a U n i ti t r w 3 ii, <br /> Septic or Holding Tank 7.SY:2 7St0 / r-epe,--- 4 <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 1JGhteir/)aht-c/.1 itin,,, Sl) ot73y,A0 7/S- 733-0906 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ?' 'o) /sue w_c 6 -/--e,.- wJ s`4'6-6-4-3 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent ignature <br /> Approved CI Disapproved <br /> 0 Owner Given Reason for Denial $ 1Z5 l I l I/o12 5 c=.. etA/t"i <br /> Conditions of Approval/Reasons for Disapproval <br /> aid s-��e "VA <br /> re,~-fs <br /> 11 ate ca.� `'1 IN UV 2 5 2025 ;I <br /> d A ,_ <br /> ,,:(natt CCrntnty <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 incheati i sl.3er viCe$Departme, <br /> $,126.12-e) k_ *.2t07 <br /> SBD-6398(R.03/22) <br />