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tt'^nr"�+-jam County — <br /> A.` Safety and Buildings Division <br /> S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> a p P.O. Box 7162 <br /> '+ Madison,WI 53707-7162 <br /> .� lloko <br /> �``o"t°ssituaw� <br /> State Transaction Number <br /> Sanitary Pq�;mit Application <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 fortes for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary l / <br /> purposes i �n accordance with the Priv Law,s. 15.04 1 (m,Stats. Q <br /> I. Application Information-Please Print All Information 60- <br /> Property Owner's Name C Parcel# p 7 Ql�q 4,10 <br /> Property <br /> LOwner's Mailing/vAddress <br /> un Property Location <br /> Govt.Lot <br /> City,State / Zip Code Phone Number ,A <br /> /y Section <br /> Lot , (circle one _� <br /> 11.Type of Building(check all that apply) T�oN; R Eo UW <br /> r' <br /> gm <br /> hor 2 Family Dwellin -Number of Bedros Subdivision ame <br /> Block# <br /> ❑Public/Commercial-Describe Use ' ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> own of L 79C� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 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 System/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 Rewired(sfj Dispersal Area Proposed(sf) System Elevation <br /> Z/ =7--\ <br /> ' <br /> V .Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o <br /> R. V V2 m rn V. C7 a <br /> Septic orltalduioaimk <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> t1umber <br /> 's Name(Print) Plumber's Sign re `^J MP/MPRS Number Business Phone Number <br /> ERUFSHOLM1 //� 227691 715-349-7286 <br /> er's Address(Street,City,State,Zip Code) <br /> X 514,SIREN,WI 54872 <br /> Coun /De artment Use nl " I I I <br /> Approved Disapproved <br /> Permit Fee Date Issued Issuing Agent Si e <br /> ❑ $ 75-- <br /> � pQ� q <br /> ❑Owner Given Reason for Denial / SOC <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach to complete phos for the system and submit to the County only on paper not less than 8 112 x tl inches in size <br />