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,'.'‹,,:;,i--'CS-T;- County <br /> , ''`,";:k:! Industry Services Division � <br /> /, ';' A.v vl e'{t <br /> ,ir: 6 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co) <br /> ;' 4"'h .' i'l P.O. Box 7162 514N1--,:2() -0a <br /> �,,, '- ax Madison, WI 53707-7162 /� <br /> .:�;;,�t,g,+� C� --021)"O2 <br /> Sanitary Permit Application St <br /> In <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (P J` "g <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 L C1.c r e t n /?I <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information , <br /> Property Owner's Name Parcel# /4/4-/O--.5-^0.5--C906 <br /> Joc(t 5-for/le ©7-OeIN^a-3�' <br /> 016 ooa <br /> Property Owner's Mailing Address Property Location 15-r t <br /> 136 k BK,,l- izef <br /> Govt.Lot <br /> City,State Zip Code Phone Number Y <br /> /� /<, Section /0 <br /> /11 /roc/4(y /14/il 511-63 7 40-366 - 6 9 (circle one <br /> T 1 N; R /°/ E ot� <br /> II.Type of Building(check all that apply) Lot# <br /> Jill I or 2 Family Dwelling-Number of Bedrooms 11 of Subdivision Name , <br /> Block# <br /> • <br /> ❑Public/Couunercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use �u s/C <br /> ® Town of / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 4 New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B ❑ ❑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.T s e of POWTS S stem/Com.onent/Device: (Check all that a..1 <br /> M Non 4urized In-Ground 0 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(st) System Elevation <br /> 1,0 0 ,-7 53"1 8 611 9'et . 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o-es <br /> New Tanks Existing Tanks G " 2 <br /> o <br /> c-,0 v� ti cn w U a. <br /> Septic or Holding Tank /ds o LIS-0 / LAI /e f e r- /� <br /> Dosing Chamber.. J -j <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 /> Rt Llt //ey k,,,,.,I / 7, . / . ) \5S / 745-- 866'4/45- 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> oZ 7 760 gw 35 Gv•e 6s7 T' <br /> lam_- . .Szf g 5 3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date ssu suin Agent Bi_•/ture <br /> $345-, 00 g zozo <br /> 0 Owner Given Reason for Denial <br /> - <br /> IX.Conditions of Approval/Reasons for Disapproval - „� <br /> APPROVED51.5 , OCOGLiio K M. be Ka f`(�J' ILS <br /> S tA- PraP14c1 5 atiafioh 1230 D <br /> _ DV <br /> JAN 2 9 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i/'. l i es in size El <br /> urnett County <br /> Land Services Cepa,' <br /> SBD-6398(R0313) /'I -11/^,/ onGv <br />