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A - `;„e <br />Industry Services Division <br />Coun �X 7 <br />A, on e /'' 3 �$"Q <br />t y {7! <br />' <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />,P <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />111/1109 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />- <br />is required prior to obtaining a sanitary pen -nit, Note: Application forms for state-owned PO WTS are submitted to <br />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 />8a 9 <br />purposes in accordance with the Privacy Law, s. 15.04( I)(m), Stats. <br />��H.� �� <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />S, -®7t” %✓ no <br />Parcel # <br />07 od0-at-e4.0 d7-.�"os <br />9✓ eS� ass�� <br />o os,- CVyoao <br />Property Owner's Mailing Address <br />Property Location <br />t / <br />S3S 11,� /^Ive A/ <br />Govt. Lot S" <br />y, y,, Section 27 <br />City, State <br />Zip Code <br />Phone Number <br />.S, , -4 ?,4" l' /" Al <br />7s(crrcle <br />one) <br />T qO N; R /6 E or i <br />II. Type of Building <br />yp g (check all that apply) <br />Lot # <br />Subdivision Name <br />❑Ior2Family Dwelling -Number of Bedrooms 3 <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />11 State Owned -Describe Use <br />El Village of <br />CSM Number <br />�y <br />Ld Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Pennit Renewal <br />❑ Pennit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />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 />HoldinoTank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />tiS0 <br />— <br />— <br />— <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />y <br />New Tanks <br />Existing Tanks <br />0 <br />v <br />_� <br />Septic or Holding Tank <br />) 5—� e) <br />a� <br />as --ea <br />I <br />kv1 e°f r, <br />X <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the PONVTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />SC //M k, n f <br />,�/ <br />�� / / <br />�+ Jr ��% <br />7/_5-- 01a'av ellu_ <br />Plumber's Address (Street, City, State, Zip Co(le) <br />III. Coun /Department Use Only <br />Approved <br />El Disapproved <br />Pennit Fee <br />$ D� <br />Date Issued <br />Issuing Agent Signature <br />11 Owner Given Reason for <br />�� <br />/ <br />Denial <br />tv <br />IX. Conditions of Approval/Reasons for Disapproval <br />E C;E � � /J E <br />I <br />APR 2 5 2018 <br />ID <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inche�.{tl;CSUt,7y,N'ETT COUNTY <br />C( ZONING <br />SBD -6398 (R0313) <br />