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County <br /> � g` =Industryervices Division.V N•ett <br /> ashington Avg Sanitary Permit Number(to be tilled in by Co.) <br /> Box 7162WI 53707-7162 <br /> r� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wu.Adm.Code,submission of this form to the appropriate governmental unit <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 y6u 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# <br /> Wlaele- /L/dkof P1 v7-61).Y•-01- 39 ly-f3- �" OS <br /> D 17 otiS- 0 67 0 <br /> Property Owner's Mailing Address Property Location <br /> /41 m ed dL -5 <br /> Govt.Lot 5 <br /> City,State <br /> Zip Code Phone Number E or y,, y,, Section 13 <br /> C// ` S"1 <br /> lq/ ih�l Al3),k— a 91 8 (circle one S[-1 G r�V 1•e s <br /> H.Type of Building(check all that apply) Lot# T 39 N; R i�/ <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms "7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> /0)7-7 Y Town of A_ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> EbBefore <br /> stemReplacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> iration Owner <br /> IV.Type of PO S stem/Com onent/Device: (Check all that apply) <br /> Nor.Pressurized In-Ground `❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Des g Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> y, <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks 2 o ,U, m <br /> a.U cn h V2 c%V a. <br /> Septic or Holding Tank �4D �YO <br /> Dosing Chamber.. s lJQ s-0ep + <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 rMP;qV_TR1,1Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> , 3 kites�r r lri-r-5'�/ i� <br /> VIII.Coun /De artment Use Only <br /> t6 Approved ❑ Disapproved Permit Fee ' ,Date Issued Issuing Agent Si lure <br /> ❑ Owner Given Reason for Denial S1/5 /7 <br /> IX.Conditions of Approval/Re o f Disapproval <br /> V[D IU) [C-7 <br /> MAY 0 9 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 GOUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />