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County <br /> Industry Services DivisionN <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> r! P.O. Box7162 <br /> Madison,WI 53707-7162 <br /> t <br /> Sanitary Permit Application StateTransactionNumber <br /> LIA <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (1 1/,91 <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#N-a.-Jg,�y� ..sas'.00.t�a,r�i <br /> p7-ad <br /> KeVItA V NO wee O 1g000 >?r�T� <br /> Property Owner's Mailing Address Property Location <br /> of ID aS4 W• G ipsjr G Govt.Lot $_ <br /> City,State Zip Code Phone Number y, y., Section 4.7 <br /> S porl4v wX �5'14,vo I T 3�_N, R JY(circlEone <br /> I1.Type of Building(check all that apply) r� Lot# ) <br /> J9 l or 2 Family Dwelling—Number of Bedrooms .S of Subdivision Name <br /> Block# V, f P ) 7 7 <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of I?as K <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑Treatment/Holdin� <br /> ❑New System �Replacement System e Tank Replacement Only El 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 S stem/Com onent/Device: (Check all that apply) <br /> tian Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ Holdm>Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal ea Proposed(s <br /> S'o t) System Elevation <br /> 4f . ? ( (0 413 o W.I t- 8G. 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer 4 <br /> Gallons Gallons Units 5 U N <br /> New Tanks Existing Tanks o a y R c�a <br /> a U �n ti rn ii U a <br /> Septic or Holding Tank /d f"Q O.f�O ( T/a ! if O✓ 'Y <br /> ►"tcN S tl�Yv /A I4 3�f� 3Ao 1N t�FJ b✓ t <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 Signature MP/MPRS Number Business Phone Number <br /> /?/G/z 6 m .1/e �f Qi S'8 S'{ 7/.S'8*4 ` -l-'7 <br /> Plumber's Address(Street,City,State,Zip Code) \ <br /> -776'o //N. 3.- W-ebSy�rr W- SytS`t3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date[sued ssuing gent Sign e <br /> El Owner Given Reasron for Denial $ /� -- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> AUG 0 8 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 1 inches in size <br /> Bumett County <br /> Land Services Department <br /> SBD-6398(R0313) u,0,6 67 3U J (IKinS <br />