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rear.;, <br />Industry Services Division <br />Washington Ave <br />County <br />Bu"o I r <br />1400 E <br />_ <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Q a� 0 S <br />Sanitary Permit Application <br />state Transaction umber <br />ft <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POW'IS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />Z 7&2-13 5OAD� <br />purposes in accordance with the Privacy Law, s 15.04(1 Xmj Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />5H RG IT LLQ <br />Property Owner's Mailing Address <br />Property Location <br />2 (c (nZ(a LJL� <br />Govt Lot - <br />-- '/. - '/4, Section aS <br />City, State <br />Zip Code Phone <br />Number <br />r <br />(circle one <br />T /7'0 N; R (% E aR <br />H. Type of Building (cheek all that apply) _ / Lot <br />� <br /># <br />% <br />Subdivision Name <br />1 or 2 Family Dwelling -Number of Bedrooms _ 3 �D ` <br />Black# <br />121 -A -T cF _-5Hfln lam' r --EA <br />❑ Public/Commercial - Describe Use <br />— <br />D City of <br />❑ State Owned - Describe Use CSM <br />D Village of <br />Number <br />r <br />Im Town of ri;ti IQN <br />III. Type <br />of Permit: (Check only one boa on line A. Complete line B if applicable) <br />A, <br />D New System <br />Replacement System <br />� TreatmenUloiding Tank Replacement Only <br />❑Other Modification ion to Existing System (explain) <br />B. <br />D Permit Renewal <br />❑ Permit Revision <br />Change of Plumber <br />D Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />Q' 7 <br />IV. Type <br />of POWTS System/Component/Device: Cheek all that apply) <br />Non -Pressurized In -Ground D Pressurized In -Ground D At -Grade D Mound > 24 in. of suitable soil D Mound < 24 in. of suitable soil <br />❑ Holding Tank D Other Dispersal Component (explain) D Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (end) <br />Design Soil Application Ratc(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />s1 <br />6.7 <br />1 rya. Fil 1 <br />&6_6 <br />Vl. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />c <br />Gallons <br />Gallons <br />Units :'. o <br />New Tanks <br />Existing Tanks <br />` c 2 VC .N a = m <br />SeQ`i` m {loLdiag.'iWm <br />Dosing Chamber / S"74 <br />Q 5'Q <br />VII. Responsibility Statement- 1, the undersigned, a the respo lity for installation of the POWTS shown on the attached plana <br />Plumber's Name (Print) <br />Plumlyf,,s Si r <br />MP PRS Number <br />Business Phone Number <br />Cony Ac Scti' <br />7!5= -56� <br />Plumber's Address (Street, City, State, Zip Code) <br />I. Count /De rtment Use Only <br />Approved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Signor e <br />- far Denial <br />37 <br />-a <br />Ix, easons for Disapproval <br />nn LPCEOV <br />Attach to complete pram for the system and sdr®t to the County only on paper not secs tbaa I ft -:11 inches in size <br />MAR 2 3 2018 <br />l� <br />SBD -6398 (K 08/14) 13'.IRNETT COUNTY UU <br />ZONING <br />