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N <br /> -ejia7;4'',;-‘ County <br /> /1; ''`•:;.4 Industry Services Division �3w y et .-e--7174" <br /> f al.� y 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> Vi,``'� 4'1 P.O. Box 7162 �y ni'+2)--4p <br /> 4; J 1'�►v O <br /> i-8 , Madison, WI 53707-7162 <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 (0234A5 <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 3 53 6 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information P gi G/L /Zeit •ne <br /> Property Owner's Name Parcel <br /> 03 2- l-15-134 of-oDad- <br /> T f ordf •as 3aso <br /> Property Owner's Mailing Address Property Location <br /> 4700 L)1 - 4-1%# a Govt.Lot <br /> City,State Zip Code Phone Number <br /> /, '4, Section (.T <br /> ft /74%0-I Pi Ai 3"'57/9 (ctrcleone <br /> T 4/ N; R /s Eor� <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms ) A Subdivision Name <br /> Block# <br /> ❑Public/Cotrunercial—Describe Use ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned—Describe Use <br /> ®Town of ...n-/J5 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pa New System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other iv(oditication to Existing System(explain) <br /> B ❑ Chance ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision Change of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> r Piessu <br /> NoPized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑-F-foldinTank ❑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(st) System Elevation <br /> 3 00 17 '-it 9 NSc 93. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -,g <br /> t' o a B <br /> Y N <br /> New Tanks Existing Tanks c o v 2 5 R <br /> X./ <br /> cn ti c:2 u..U a- <br /> c.U <br /> Septic or Holding Tank /0.S—f, /0..C-0 / ..2—i%X./7‘0aft,lib s" K <br /> Dosing Chamber.. j :}1 <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 /> 1Z1 c.// ./`/o/0 k i h s /21-14.~, /4 :- of A..5--6'57 7/. -: „vG 0— y 45-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> . 7 v K. .7.5' 14✓'t6$f r 14, S 8 5 <br /> VIII.County/Department se Only <br /> vCJ�pproved ❑ Disapproved Permit2Fee DDat Issu d suing A ent.Signa e <br /> ❑ Owner Given Reason for Denial 3V'. 5/h1/ 0 0 i <br /> IX.Conditions of Approval/Reasons for Disapproval / C r IE I d r <br /> 4 AlisfiK wal w abt lee al• 4dew pciorc iu►s iµsico,Ua :� mars. 11 <br /> # I ( j- ta <br /> se Same BirACIANAa k, sat +esf: MAY 8 <br /> T �� 2020 J <br /> i3 Aiew welt W4464 be, a off bei- 1/II'AAN.!'1{�ef �--4 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 las 11 in es in s <br /> urnett County <br /> Land Services Department <br /> laSx - <br /> SBD-6398(R.0313) <br /> d3 $375 <br />