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✓.+ 'k�� County <br /> Industry Services Division all,r1-% <br /> ' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �p ij, P.O. Box 7162 �7� /-� <br /> 705 <br /> S �i Madison,WI 53707-7162 <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 r" 4ev- ✓ <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 information you provide may be used for secondary 76 qel <br /> purposes in accordance with the Privacy Law,s. 15 04(l)(m),Stats. ZO( <br /> 1. Application Information-Please Print All Information CI'1 sate�� <br /> Property Owner's Name Parcel# <br /> �] oa-aha-d-�m•/�-,�a,.f'iaf= <br /> �an /Y n Of t rJs n O 7/DOO <br /> Property Owner's Mailing Address Property Location <br /> /0 1 7(e Govt.Lot <br /> City,State Zip Code Phone Number y '/., Section <br /> C'a I 0 x �. sy 3O (circle one) <br /> ( I e T �A N; R /G E o& <br /> IL Type of Building(check all that apply) Lot# <br /> f q Subdivision Name <br /> I ort Family Dwelling-Number of Bedrooms �, <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City,of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use A <br /> © Town of h 0° <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System /t' Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Penni[Renewal El Permit Revision Change of Plumber <br /> ❑Chan ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onenUDevice: 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(gpdsf) Dispersal Area Required(sf) Dispersal A7Proposedf) SystemmElevation <br /> Vt.Tank Info Capacity in Total #of Manufact <br /> Gallons Gallons Units U v y <br /> n v u v y <br /> New Tanks Existing Tanks <br /> c V <br /> Septic or Holding Tank .2.0-,041 f e r <br /> Dosing Chamber <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 MPIMPRS Number Business Phone Number <br /> A ?rc/C -- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .17769 //_r. 3./ LV 446,f (r l WT .5_4',fl 3 <br /> VVII1II.County/Department Use Only <br /> PermitFee O Date Issued Issuing A Sign ture <br /> -L Approved El Disapproved <br /> S <br /> ElOwner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> DECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 111 x 1 nch in si99 Z 6 Z015 <br /> SURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />