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`t,,,xnr„!5 County . <br /> %', Indust Services Division /-1-- <br /> 1400 E Washington Ave <br /> = :�$pe <br /> 1=.1 P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' ` Madison, WI 53707-7162 SPN 'c 1 -Ob <br /> t ,. C27---a1--05 <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 '' <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. � <br /> 1. Application Information-Please Print All Information <br /> -U7-U(js o'd 35 i eeil Vi90 <br /> Pro erty Owner's Name Parcel# 1 '��0 <br /> °� a✓G( N10�'- (770002;33)7 Z-7303 UOCC <br /> Property Owner's Mailing Address l Property Location Z .2-3 <br /> 1 0 2, k&,3 a 'fi Ave IV Govt.Lot <br /> Ci State `l j� I Zip Code PhoneNumber �j VY '/,,C �.t//4, Section 7j7 <br /> 5Y'OO /074 PA ✓i� N/V 6 1(4� � -)6✓-0 _o( O T3 N ; R )7(circle <br /> Eoro& <br /> 0Type of Building(check all that apply) Lot# <br /> ,1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> 0 City of <br /> ❑State Owned-Describe Use <br /> CSM Number 1. <br /> 0 Village of <br /> Town of 0cA A i e i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1513 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> licl Non-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 /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) <br /> � ) ; C , (�j /s <br /> VI.Tank Info Capacity in � �� � �7 / �` g 7`� <br /> Gallons Total #ofo <br /> Manufacturer 1 tu U <br /> Gallons Units ; e Z <br /> New Tanks Existing Tanks +, \^ P o U vz 2 w C7 0. <br /> Septic or Holding Tank WOO wi Via d "" < e - `V El 0 0 0 0 <br /> t <br /> Dosing Chamber 0 0 0 0 0 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> \ <br /> Plumber's Name(Print) Plumbe Si atur MP/MPRS Number Business Phone Number <br /> Pat Kissack (? #' Y� 881072 715-520-2335 <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> W7003 Rappy Lake Rd.,Trego WI 54888 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued lssuin/g Igentlirnature <br /> 0 Owner Given Reason for Denial $ 37•�! Z - 2/ (A/• ,r <br /> IX.Conditions of Approval/Reasons for Disapproval t-<.t 1 b5".&4? $21 5 <br /> D E © e . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 -I c I:'n sjeAN 2 `* 202) <br /> SBD-6398(R03/14) =urnett County <br /> Land Services Department <br /> __ AIM- <br />