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County <br /> Industry Services Division 13u.r�G <br /> ;fir Q) 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> �s`'� p P.O. Box 7162SAO—19 — 19/ <br /> Madison,WI 53707-7162 <br /> j <br /> Sanitary Permit Application State Transaction Number <br /> `In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit AD 76er <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 infonnation 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# p ti <br /> ��er+ a /Ytra qe1 04 <br /> 8- 07-ott ��',old ao ikw/94P <br /> Property Owner's Mailing Address Property Location <br /> fD 33 D 4-c I led Govt.Lot <br /> City,State Zip Code Phone Number y,, '/,, Section <br /> �/� 5 e i?5 3 circle one) <br /> II.Type of Building(check all that apply) 99 Lot# T ?c1 N; R E or� <br /> 01or2 Family Dwelling—Number of Bedrooms 0' Subdivision Name <br /> 4. <br /> B lock# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> Town of !Yt C C M it h <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System WReplacement System ❑Treattnent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ElPennit Renewal ❑Pen-nit Revision ElChange of PlumberFEIermitTransfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ner <br /> IV.Type of POWTS S stem/Corn onent/Device: (Check all that apply) <br /> Ivor Pressurized In-Ground ❑ Pressurized fn-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ EfoldutiTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3oa s5 Goo boo Ss.d <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> U 4 w +^ <br /> New Tanks Existing Tanks o Y, w cNd <br /> a,U in y w C7 a <br /> Septic or Holding Tanis INS- �6S d 7^h i a 1!e r >e <br /> Dosing Chamber.. .L <br /> 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 /> 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 770 o 3 - W.-P ple, S—y 8 S3 <br /> VIII.Coun /De artment Use Only <br /> ved ❑ Disapproved PenuitFeee Date issued umg ent Signature <br /> ❑ Owner Given Reason for Denial $ ✓0 ? 23 �1 q <br /> IX.Conditions of Approval/Reasons for Disapprp val <br /> 1w,Fcja( rAW+ h&VC 1.2"of co�cr. <br /> - ,r-7cvafio� r►a; +bc exacWN a-E 95 2. SEP 1 9 2019 <br /> DraimPt l ►Rug►- be _io 4y^ovA ,t kc. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/3. 11 inch urnett County <br /> Land Services Department <br /> 0-4-4()b-I ss4 p tis <br /> SBD-6393(R0313) <br />