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County <br /> Industry Services Division u r n t <br /> 1400 E Washington Ave Sanitary Pit er to be tilled in by Co.) <br /> P.O. Box 7162 r9 <br /> Madison, WI 53707-7162 <br /> sg�J50 <br /> - <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 govenuriental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS 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(t)(m),Slats. Gr I Yf 9 /.-W V <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> d7_ Olpl-.�- 40-. tS=/4, s OS <br /> G r !S c raga v e,t — 0/I000 <br /> Property Owner's Mailing Address property Location <br /> ` J1 il S J4,w of /4v c N Govt.Lot 2 <br /> City,State Zip Code Phone Number 'ya, Section 1 4( <br /> At 015 /MN ciacle one) <br /> II.Type of Building(check all that apply) Lot# T VQ N; R <br /> 1 or Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Coatmercial-Describe Use <br /> - ❑ City of <br /> ❑State Owned-Describe Use CSNI Number ❑ Village of <br /> JX Town of J4LK•J, �+ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. K New System ❑ Replacement System <br /> y p y ❑Treatment/Holding Tank Replacement Only ❑ Other Nloditication to Existing System(explain) <br /> ❑ Chan, List Previous Permit Number and Date Issued <br /> B. El Permit Renewal El Permit Revision Change of Plumber10��,p <br /> enni[Transfer to New <br /> Before Expiration ner <br /> IV.Type of POWTS System/Component/Device: (Check all that a I ) <br /> 9 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.Dis ersaliTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sk) System Elevation <br /> 300 , S 666? boo 93.Sa 93 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o 'o � <br /> New Tanks Existing Tanks y m <br /> 0 <br /> U �Z h 62 Z U a <br /> Septic or Holding Tank 7,s-•o ��� G✓r r,f ti r <br /> Dosing Chamber I <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PO WTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature �,/ MP/MPRS Number Business Phone Number <br /> /e_/e- /4e k.N-0 � --� wlr J.sB.s' 71do-864--41/s 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> II.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Sigma re <br /> Ap ���proved ❑ Disapproved S Om <br /> ❑ Owner Given Reason for Denial C.J-y-J L <br /> IX. <br /> .CConditions <br /> off Approval/Reasons for Disapproval/'/`!� /�/sitile:n� /oQ.�osGDv�ror///nr{ ouP✓�rC�C�. ECED V/ E <br /> Attach to complete plums for the system and submit to the County only on paper not less than 8 IC x inc in s <br /> 13URNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />