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.— Industry Services Division Countyj <br /> =" \;`/-• 1400 E Washington Ave /lar kf 1¢I-1-- <br /> PI !$a P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction <br /> Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 4/23110 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / <br /> I. Application Information—Please Print All Information CO2- /i/VAiek,l I-I4-4 <br /> Property Owner's Name Parcel# <br /> 9ceJ Te /I- (37-0-r,-Z yp-,6-/2 z of- x- ,)/at, <br /> Property Owner's Mailing Address �j Property Location tt %5100 <br /> /1/f?/ 3 ' / t- Govt.Lot +� <br /> City,State / ZipCode Phone Number /, /,, Section <br /> y J//'�`�016 kJ r 5�e5/'(S .cele one <br /> '�-ww/"`` T I l v N; R / E of) <br /> II.Type of Building(check all that apply) Lot# <br /> XI or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> H Town of [7q K Io••el <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> 1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> fa Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dis sal Area Proposed(sf) System Elevatio <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> :: <br /> Gallons Gallons Units i o v <br /> c, zVINew Tanks Existing Tanks v 2y o <br /> c. U n y rn u. Q n. <br /> Septic or Holding Tank Q/y0 boo / ka�,Lj <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cc's Name(Print) / Plumbe' Signature MP/MPRS Number Business Phone Number <br /> (Of* /Olf4ACl/ - 7/G 86i954/ 7/5--1g-a2oZ <br /> Plumber's Address(Street,City,State,Zip Code) f , / <br /> 6667/ 4vWr nl 1/e i/J/ 1V e6s ier L✓t' 51/69 <br /> VIII.County/Department Use Only <br /> Vk4pproved ❑ Disapproved Permit Fee w� Date u/ � gent Signa re <br /> 0 Owner Given Reason for Denial '315 00 7 /'"fl <br /> IX.Conditions of Approval/Reasons for Disapproval • 3 " <br /> *nr)ftmgeict stuts4 in. kvei. :),,___....,...,.. . ,._...„,.,,,, <br /> .;~' , MAY 4 2020 <br /> Li <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 u2 a 1 finches in size <br /> ..- <br /> Jur;lett County <br /> ,_;1,x,Services Departrnent i <br /> SBD-6398(R.08/14) * ��4o U. 8131 <br /> 'To 540 c. <br />