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.-e 2744A;.l County <br /> / X cA Industry Services Division j3t,-✓n-ems <br /> f Eli `4. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> `,, 'I P.O. Box 7162 <br /> ' ',...........-./,',1Madison, WI 53707-7162 9,0. iq-2/5 <br /> Sanitary Permit Application State TransactionNu <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ' ' �'2� <br /> Number <br /> " <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 ?/ •7 6,1 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 7 / <br /> I. Application Information—Please Print All Information S f 1L ft RSC! 3;- <br /> Property Owner's Name Parcel#ad-,���,� ../..S.-...057. �— <br /> O <br /> T1i h . p r1 t, / tk- 07 0-' <br /> coo--013000 <br /> Property Owner's Mailing Address Property Location 4i 21212- <br /> '7..5-it 1' <br /> 12ZZ7•S-k '' r/' /' ' St Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section <br /> W e.b S fe r tv.l .S"-/ fl 9 3T ��r N. R 1 ciircle ore) <br /> nee) <br /> II.Type of Building(check all that apply) Lot# <br /> N I or 2 Family Dwelling—Number of Bedrooms 4.) Subdivision Name <br /> Block# <br /> ❑Public/Comunercial—Describe Use <br /> ID City of <br /> CSM Number El Village of <br /> ❑State Owned—Describe Use <br /> Town of flui 155 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement 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.T le of POWTS S stem/Com.onent/Device: (Check all that a..l <br /> ry N suriCIElr Preszed 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 6 0 , -7 y J 9 e-Ls-C 93:5— <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 5)Gallons Gallons Units o -a <br /> U v <br /> New Tanks Existing Tanks o .1, E ,c ro 5 <br /> c,U vti cn u.3 0.. <br /> Septic or Holding Tank O D /�' X <br /> Dosing Chamber.. I -)• <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POVVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> pgG 91S-71 <br /> Plumber's Address(Street,City,State,Zip Code) I <br /> 7760 44 - ?S iv eh s/e v Lli.1 c 93 - <br /> VIII.County/Department Use Only <br /> Pennit Fee Date <br /> ss/ <br /> suin. Aget Sit-ature / / //Approved ❑ Disapproved $z 'A1Qv /,....,-- <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval OF v/C. V I V C- <br /> it acct ali la& 5efrkRd(s. <br /> ! I OCT 1b 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s 1 inche841“ �urnett County <br /> Land Services Department <br /> SBD-6393(R0313) a:00414 /315.00 <br />