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oamarai,> County,...)1 Industry Services Division .16(//''!N <br /> Et 8 ' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> u�: P.O. Box 7182 <br /> '6,� Madison,WI 53707-7182 A-N,22.23o <br /> ° slor�rtis CST-c-,22 --LTD ���S6a3 <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(IXm),Stats. 12 3 'i)ctioter L IV <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel#' <br /> i irti -97)1 ii• '05 . 7,V 903 So i t 00 ........ , <br /> Property Owner's Mailing Address -/ Property Location <br /> 2-9 q9,7 /�e C7 Lr/1 9 f`e_ Govt.Lot <br /> City,State Zip Code Phone Number 4/f�/<,S 3, Section /2. <br /> Si/� /� (circle one) <br /> �� Y„� SSO7 �l �,o� T3 el N ; R/t/ Eo> 7 <br /> II.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling—Number of Bedrooms Z I Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# 1_f/2.1/e_ /4 illo 5 <br /> 0 City of <br /> ❑State Owned—Describe Use <br /> CSM Number/ 0 Village of g <br /> 5(J4D11 l-o-�-l I� Town of (/j/‹. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. lit 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 ❑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 /> oR Aion-Pressurized In-Ground. ❑Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑ 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 /> 3 0 o Rate(gpdsf) 0. 7 y 1-� (is.Z 93 . i/ of dee,4,- <br /> VI.Tank Info Capacity in <br /> B � <br /> Gallons Total #of Manufacturer m te U '" <br /> New Tanks Existing Tanks Gallons Units Q :3 8 ,n <br /> a U v� n is. C7 R <br /> Septic or Holding Tank 4/e LI/ I D 0 0 I Ake R o -/i/o/cJ 0 0 0 0 IDa <br /> Dosing Chamber ❑ ❑ .. ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown op the attached plans. <br /> PI b s Name(Print) P1 14),'s S. stun MP/MPRS Number Business Phone Number <br /> C L c'G 41,7 / - l ? 9 3 U 7 95""�-,A6 /- //o® <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 0-9 / l 7071 574 t 5% , C41 r)< 4 ctzJ— 5—`10 1 L/ <br /> rV�III.County/Department Use Only <br /> gy Approved 0 Disapproved Perm'\ ,..e� Date Issued ui g —sued Si <br /> 0 Owner Given Reason for Denial $Li(/Z/ 9 ie.7/�? J i <br /> IX.Conditions of Approval/R. sons r Disapproval ,5 Ca1�I/ "_ � <br /> Pi eu l ed' $ 4. C'..��`� -1 1 -Th 1 <br /> u5� c. .:� 2022 <br /> Yr <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1 inches in size 1 L County <br /> vices Department <br /> SBD-6398(R03/14) <br />