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+I- Court <br /> f f �? : Industry Services Division P1 <br /> r41 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> '; `y P P.O. Box 7162 rg452-, <br /> / Madison, WI 53707-7162 <br /> s�nl-l-7 <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 fors for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infonnation you provide may be used for secondary <br /> purposes m accordance with the Privacy Law,s. 15.04(I)(m),Stats. ••�� <br /> L Application Information-Please Print All Information vCNNYr' <br /> Property Owner's Name <br /> e1Dld`gl ./t-l� <br /> ISM s` <br /> / C+)`_ <br /> Property Owner's Mailing Address Property Location <br /> /Q C 4ft tu/-e IN ezld 414 Govt.Lot <br /> City,State Zip Code Phone Number y., Section 074 <br /> St eVZ4 V P)IV "�a�f77 (circle one) <br /> /Y)A 6- c n T 40 N; R /-I,- H o67 <br /> II.Type of Building(check all that apply) Lot 4 <br /> �l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4 <br /> ❑Public/Cormnercial-Describe Use ❑ City Of <br /> El State Number ❑ Village of <br /> State Owned-Describe Use i ` <br /> V, l in n � Town of B'l S <br /> I r, <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System I ❑ 1'reahnenCt{olding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑Perit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized Tn-Ground ❑ Pressurized In-Grotmd ❑ 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 Sail Application Rate(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 N <br /> New Tanks Existng Tanks <br /> S Hlding Tank 70U 3CQ irob ` LvI Yf`f tv X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,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 /> Plumber's Address(Street,Ny,State,Zip Code) <br /> VIII.Court /De artment Use Only <br /> Approved ❑ Disapproved Permit Fez Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial $ <br /> I%.Conditions of Approval/Reasons for Disapproval <br /> AUG <br /> Attach to complete plans for the system and submit to the County only on paper not less than B 1/?x 1 y �-, -,,,7 <br /> TY <br /> ZO Kv6 <br /> SBD-6398(R0313) <br />