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County i=a{�As rv. Safety and Buildings Division Ov'L tJ C- <br /> 03 <br /> 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> X5880 1 �' <br /> Sanitary Permit Application <br /> State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 43,30)8 <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 -7 / <br /> purposes in accordance with the Priv Law,s.15.04 1 m),Stats. Dol /v Q ,5Vnx� (`,..1r w / K <br /> 1. Application Information-Please Print All Information Yid <br /> Property Owner's Name Pmcel# <br /> AAI d- P,4* NAiSON (/(). 07--j3Y^ —37' 18—a1 S-r5=436a➢ au <br /> Property Owner's <br /> Lailing <br /> Adrss Property Location <br /> ewo✓V CiT Govt.Lot <br /> City,Stae <br /> Zip Code Phone Number y,, y., Section <br /> R (circle on <br /> lOV& � M� SSo 33 T _Z N; R I� Er� <br /> 11.Type of Building(check all that apply) Lot# K ��� <br /> �.1 or 2 Family Dwelling-Number of Bedrooms <br /> J Subdivision Name <br /> Block# LA tr / LAA cc lot lcr- <br /> D Public/Commercial-Describe Use D City of <br /> CSM Number D Village of <br /> D State Owned-Describe Use n f <br /> own oTA k <br /> f try Za—��-.-- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) - <br /> A. <br /> d.New System D Replacement System D Trcoment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. ❑ permiRenewal El Revision ❑Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> t <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com oneotlDeviee(Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade S6dound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.DispersallTreatment Area Information: <br /> tDesignlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> To 6 N S� y.fok Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o u _ 29 <br /> New Tanks Existing Tanks ' 0Holding Tank 000 O^0 <br /> Dosing Chamber O V <br /> VII.Responsibility Statement- 1,the undersigned,assu respoo ' ility for installation of the POWTFMP;P�RS <br /> n on the attached plans. <br /> Plum 's Name(Pn Plumber' ign Number Business Phone Number <br /> C ag 7i - V6 i <br /> Plu 's Address(Street,City,State,Zip Code) <br /> 6-rAw fK S � L%),f <br /> V II.Court /De artment Use Only <br /> Permit Fee Date Issued lssuin em Signature <br /> proved El s, pmved 5�7-c <br /> D Owrter Given Reason for Denial <br /> IR.Conditions of Approval/Reasons for Disapproval ECOVE <br /> SEP <br /> Attack in wmpkte plain for the system and sobmit to the County only an paper not las than a in a l l iacba' <br /> 6 !T <br /> SURNETTCOUNTY <br /> SBD•6398(R. 11/11) ZONING <br />