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N <br /> >- •• <br /> (.4-'1 ,-1.. '`<,=„, Industry Services Division du. G <br /> ;:id .: t; ; „ fr. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> j :;4: , . 54N—,„1----1,2 <br /> 51 <br /> P.O. Box 7162 <br /> t;:,;;:.)1 Madison, WI 53707-7162 <br /> '11,1,-....., • � l51 L3Saq <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with BPS 383.21(2),Wis.Adm.Code,submission of this Form to the appropriate governmental unit <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 // <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. (,./. 0011.cen /7p' <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ) Li0-/t,-3a -y-04- 000 <br /> 4/154 pati Ka/o 07- 3Jr- - Of freed” <br /> 2-7-111 17-7-111 - ot7eoo <br /> Property Owner's/Mailing Address Property Locatio 1< <br /> 6le7/,1 keoltbe /2 et . Govt.Lot <br /> City,State Zip Code Phone Number <br /> v4, %, Section 3� <br /> t~th lay feh Al// <br /> 3•s-73S (circle one) <br /> T I{/ N; R /0 Eor('4` <br /> IL Type of Building(check all that apply) Lot# <br /> gI ort Family Dwelling-Number of Bedrooms of d d. 3 Subdivision Name , <br /> Block# <br /> • <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Town of I wtf S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. J New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 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 POWTSSystem/Component/Device: (Check all that apply) <br /> [` Mori'_Pressurized In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Iioldm�Tarik 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) Dispersal Area Proposed(st) System Elevation <br /> y0 0 . 7 ‘1,1 9 gra 9.1••— <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o B <br /> New Tanks Existing Tanks w o Ti . ��{ <br /> S <br /> E.:u rn �., u.u 0.. <br /> Septic or Holding Tank /0 G a /04t9 / _2-k t-%/11,4710 - X . <br /> Dosing Chamber_ . - ! .)' <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> /G f ,4 Oto/C i or 1 / a /j"p-. )4AS"8.5—/ 7/s=846`y/.f 7 <br /> Plumber's Address(Street,City,State, <br /> Zip Code) ,_ L`(� 9 C <br /> .} 7 Ito o ,w, 3.7 /y-.6,f Y- Gt77 J 7 a /3 \ <br /> }VIII.County/Department Use Only <br /> {CJ Approved 0 Disapproved $ <br /> Permit Fees Date Issued Issuin it)g•ent S. ature <br /> 0 Owner Given Reason for Denial �`� /—��'�-r iuew.mdea se3lnleg PUW') <br /> IX.Conditions of Approval/Reasons for Disapproval • <br /> 9 I elc 4iL <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/3 xmdse i <br /> rj/* 0c:; '()'aC___,e04� <br /> SBD-6398(R0313) 0b <br />