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County <br /> -' Safety and Buildings Division �' <br /> ?" D 201 W.Washington Ave.,P.O.Box 7162 <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> *.:SPS t l Madison,WI 53707-7162 -7, <br /> Sanitary Permit Application State Transact1ion No berm <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit GovN;ry /J t ille v <br /> is required prior to obtaining a sanitary permit. Note:Application fors 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),Stars. ����/SOV <br /> 1. Application Information-Please Print All Information <br /> Property ner's Nagle Parcel# <br /> • -3T os-ao5'-�Kt»o <br /> Property Owner's Mailing Address Property Location <br /> 3076 d6ojt,44� e� Govt.Lot_ <br /> City,State Zip Code Phone Number , <br /> Ou /,, /,, Section ' <br /> L/Lt•�aL/' _I r�� /cIrCIC on <br /> T �/l N; R �b Eo� <br /> II.Type of Building(check all that apply) � Lot# <br /> N�I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM <br /> El State Owned-Describe Use Number ❑ Village of <br /> L <br /> Town of SItJI <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System VReplacement System ❑Treatment/Holding Tank Replacement Only ❑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 /> IrNon-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed is System Elevation <br /> 36 1 . -7 1 If Z-1 I V01 1 Cie6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w vu v m in <br /> 2 0 2 n <br /> a C% un — rn <br /> Septic or Holding Tank <br /> Dosing Chamber �� <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Plumbe ignaturc / MPiMPRS Number Business Phone Number <br /> 055 D� e� /W"., BS�gS ?is-5G(, -ozo z. <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> F-7220 "ei.,Iel 1.J <br /> VRI.Coun /De artment Use Only <br /> Approved ❑Disapproved PermitFee Date Issued / Issuing Agent ign ture <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> le,151 /ha/a i'v ACC se"batler. Ce,t f«L,-,✓c of %ocvv C.:v< <br /> nn <br /> E(�1u1�� V <br /> = 33'+ 3' for AbsorPl;oniGelCs sefdail�'. lei `/ <br /> SEP 16 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inc <br /> latil <br /> 6URNETT COUNTY <br /> SBD-6398(R. 11/11) ZONING <br />