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County <br /> Industry Services Division BL&V n t- ' <br /> >, 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> l33 <br /> Madison,WI 53707-7162 <br /> ti rS,Y' <br /> na- <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 G 14111 <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 fl ���+q 1(p <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information IV 6 �r 1-P_(SOH L K, IZI/ <br /> Property <br /> Owner's Name Parcel 000 Q <br /> Alb ert' Le, j3 L t, 07-03y'd� C7��.©®� �i�4 <br /> A t <br /> Property Owner's Mailing Address C Property Location <br /> 0 �3 �� J 3 Jl J�' Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 3 <br /> Cti e le k Wr 3`1 U.9 ircle one <br /> H.Type of Building(check all that apply) Lot# T 3 7 N; R �� E or <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> s <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of_ <br /> Town of /r1_d'e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment(Holding Tank Replacement Only ❑ 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 POWTS System/Component/Device: Check all that apply) <br /> El ion Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 9 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ I folding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dis ers'al/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> `300 33y <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons. Gallons Units ;, o- 2 <br /> New Tanks Existing Tanks o i4 <br /> c.U in rn ti iJ n. <br /> Septic or Holding Tank Y'40YO <br /> Dosing Chamber.. t-p�oO <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 S�igna e MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � 776 p A 7--, J41 e6S 1.-,- Zvi . fs l 3 <br /> VIII.Coun /De artment Use Only <br /> pproved ❑ Disapproved Permit FeeDRate Is ue Is s ent Signature <br /> ❑ Owner Given Reason for Denial $ <br /> IX.Conditions of A I ovalfReasons for Disapproval <br /> APPOVED ECEOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In s 11 in in e <br /> FumEetutounty <br /> SBD-6398(R0313) Land Services Department <br />