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- � County <br /> I� <br /> /r� �',_ Industry Services Division U U r ri e <br /> --- --- <br /> , d 5 it �; P _ 1400 E Washington Ave Sanitary Permit Number(to beadled in_by Co.) <br /> -- — Madison, WI 53707-7162 <br /> ' P.O. Box 7162 <br /> 49 ems! <br /> Cam- v <br /> 8 3 <br /> Sanitary Permit App <br /> lication State Transaction Number <br /> [n 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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal[nfonnation you provide maybe used for secondary 3138 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. a� <br /> I. Application Information—PleasePrintAllIa ormation /�i�S�vak" /` 'SAX. ID ZOo <br /> Property Owner's Name Parcel# p (� <br /> 1J�r►7. /-/C f�'rs..✓�O{ • o7—O��-�"t/b—r'y—/9�.Sr .S� C> ,3 <br /> Property Owner's Mailin Address Property Location <br /> .syo 7y Govt.Lot -3 _r <br /> City,State Zip Code Phone Number /, '/<, Section <br /> 1?O5 ev;i(e M Al Ss�i O (circle one) <br /> II.Type of Building(check all that apply) Lot# T � N; R�_E or(� <br /> I or2Family Dwelling—Number ofBedrooms Subdivision Name <br /> B lock# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> Town of _.'CO,1- <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y �Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner ZID� 1(2 12Ca <br /> IV..jr' `q of POWTS.S stem/Com onent/I?evict (Check all that apply) <br /> ❑Non it�e strrize <br /> ai d In-Ground ❑Pressurized[a-Ground ❑ At-Grade 51 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> z WTI.=. <br /> ❑€ialdtnyTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> W. et sal/Treatment Area Information: �. <br /> Desfan'Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> y s'a yra y s' 6) Ss D <br /> VI.Tank Info Capacity in Total #of Manufacturer V <br /> Gallons Gallons Units n P <br /> New Tanks Existing Tanks o <br /> Septic or Holding Tank �d Uv �a 2 <br /> Dosing Chamber_ (Pat/ 64/ <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 Num Business Phone Number <br /> ber <br /> ( �/V /C/h <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o �1�-t 3� PV-e 5s7'r�- b--�r 19 3 <br /> r'App <br /> /De artrrient Use Only <br /> El Disapproved Permit Fez Date Issued�j� Issuing Agent Signature _ <br /> ❑Owner Given Reason for Denial Z <br /> s of Approval/Reasons for;Disapprovalme f AEU Wkrli-S <br /> «� � COWH y �� s fry ►'��u!�S APR.2 6 2024 <br /> ��. .� -S s I tv 6anA rtmut"d <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/2 s 11 inc es in size urnettCC)unty <br /> Land Services Department <br /> cRn_��oQion�t� �1 <br /> k# 5U 4� <br />