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fF <br />Cou 4 <br />s''` <br />�_ ° '(k4 � ,vIPU'TER/SCANNE� <br />Indust Services Division <br />Industry <br />j c� rn ie /''X 3 �$'Q <br />Sanitary Permit Number (to be tilled in by Co.) <br />t : ,. <br />51 <br />1400 E Washington Ave <br />P.O. Box 7162 <br />A N <br />Madison, WI 53707-7162 <br />CSC �� o <br />Sanitary Permit Application <br />State Transaction Number <br />11/1119 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />11 - <br />is required prior to obtaining a sanitary pen -nit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal infonnation you provide may be used for secondary <br />�a 9 <br />purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. <br />a <br />RCS <br />I. lication <br />A Information - Please Print All Information <br />�f w�j <br />Property Owner's Name <br />Seot q' re ✓ �e ufS� �t <br />Parcel # <br />07- CIAO -A- No -lb --d 7-,�'os <br />= <br />eSa <br />o o3 �3Y6 00 <br />Property Owner's Mailing Address <br />Property Location <br />S3 9 l k r� e Al <br />- <br />lqv <br />Govt. Lot ,S <br />y, y,, Section al 7 <br />City, State <br />Zip Code <br />Phone Number <br />S. $4 ?,4 1A Ncucle <br />one) <br />�� /� <br />T N; R E ore <br />11. Type of Building (check all that apply) <br />Lot # <br />❑ I or 2 Family Dwelling - Number of Bedrooms <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />11 Village of�y <br />CSM Number <br />pp <br />lc9 Town of <br />I11. 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 />❑ Pen -nit Renewal <br />❑ Permit 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 S stem/Com onent/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 />X Holding;Tank ❑ 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 />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />v <br />Units o <br />B <br />New Tanks Existing Tanks <br />•� o � 2 � <br />y � <br />c, U ul ti rn <br />u U a <br />Septic or Holding Tank <br />5--,* e) <br />a�47 <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />/21 e,& /c, n s <br />1? 145 fJ_/ <br />Plumber's Address (Street, City, State, Zip Code) <br />d 776 0 At 3� w _e 6stY.- wT— S-ygq <br />III. Coun /De artment Use Only <br />Approved <br />A' <br />❑ Disapproved <br />Pennit Fee D <br />0� <br />',37-5, <br />Date Issued <br />Q <br />Issuing Agent Signature <br />11Owner Given Reason for <br />3 7S'- <br />S /' / O <br />Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />" � � p E <br />D <br />vp <br />_n <br />I <br />APR 2 5 2018ID <br />,-„ iu—liplete Penns wr me system anti summit to me t ounty only on paper not less than 8 1/2 x 11 incheWiIINETT COUNTY <br />ZONING <br />SBD -6393 (R0313) <br />