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y.'.YF:hB�fi�ti County Industry Services Divisionkr <br /> 7; U j 1400 E Washington Ave Sammy Permit Number(to be tilled in by Co.) <br /> r PS #j P.O. Box 7162 ��J1✓ / <br /> Madison,WI 53707-7162 <br /> r" <br /> S. <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 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 d 9013 <br /> purtioses in accordance with the Privacy Law,s.15.04(l)(m),Slats. <br /> I. Application Information—Please Print All Information E 'Y-44-W I-ei v e N /fie% <br /> Property Owner's Name Parcel# <br /> !C� raid U o7—odo—d-9o-16—ib-o7-Sasoa o <br /> 1 p <br /> Property Owner's Mailing Address Property Location <br /> � 9.3a . -e w Ale— N. Gov't.L t 5-CLI-Ag 4- <br /> City,State Zip Code Phone Number �(r;' ' y, Section <br /> on <br /> eEi,� da/-e- 11')N SSyA � 7•G�,33/`Sd HS (circle o <br /> --do_ otf� <br /> IL Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling—Number of Bedrooms <br /> Subdivision Name <br /> Block# <br /> ❑Public/Cormneraial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe UseCS`M Number ❑ Village of <br /> V <br /> 1/ 'ltd g� ® Town of Ca/04k,, , <br /> III.Type of Permit: (Check only one box on line A. Complete line Bif a tppliclable) <br /> A. <br /> ID New System El 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/Comonent/Device: (Check all that apply) <br /> ID Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ <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) i Dispersal Area Required(s0 Dispersal Area Proposed(s0 System Elevation <br /> `Iso . S 900 Sao <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v c v .so <br /> o m `� <br /> U in m iF. U a <br /> Septic or Holding Tank /ed o /OOo <br /> Dosing Chamber 666 FJ� <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 SignatureMP/MPRs Number Business Phone Number <br /> /tick /z�o /moire s / ,A2,Q Sr5'1 ?is=866-of Ix 7 <br /> Plumber's Address(Street,City,State,Zip Co/die)) <br /> VIII.County/Department Use Only <br /> Approved [I Disapproved Permit Fee 6 Date Issu <br /> ❑ ed Issuing Agent i arc <br /> D <br /> / C .GPiL4 <br /> Owner Given Reason for Denial 3'75-- �4r.t ' �(i ��S <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 S 112 x 1 t inches in size <br /> SBD-6398(R0313) <br />