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/ u '+`i• County _�l <br /> Industry Services Division Aa t,n <br /> .fit Q 1400 E Washington Ave SanitaryPermit Number(to be tilled in b Co.) <br /> ASPS,, �l P.O. Box 7162 e/ �� y <br /> Madison,WI 53707-7162 1:w7 (aJ <br /> Sanitary Permit Application State TmnsactionNumber <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 POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Sd 6 <br /> I. Application Information-Please Print All Information Qit 1-C <br /> Property Owner's Name Parcel# <br /> J /�eilrN o7- oa$_d. 4o-ly-�o-s-oS <br /> oob-0 00 <br /> Property Owner's Mailing Addre§s Property Location <br /> JP6 3-or d 7o t Govt Lot 6 <br /> City,State Zip Code Phone Number y,, %, Section <br /> AJ iY-+fit 04ks /YIN 6_3_47-�o77 6Id - SOY-6N7If/ (circle one <br /> II.Type of Building(check all that apply) Lot# —�— E o61 <br /> T e N; R <br /> 111 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of ,lee# <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System J@ 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.Type of POWTS Sys tem/Component/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ® Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> yso 1 /. J z./_f-a 1 sol <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'� <br /> New Tanks Existing Tanks u <br /> aU v, H <br /> Septic or Holding Tank 1 /doe <br /> Dosing Chamber epee, 0,00 <br /> VII.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 /> /L #0 e- ?7Z/Z/ Sys/ lis=�G6- eYl '7 <br /> Plumber's Address(Stree',City,State,Zip Code) /amu p'c4 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signator <br /> $ o <br /> �j <br /> ❑ 37-,5-. ,-Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 1/2x 11 inches in size <br /> 3BD-6398(80313) <br />