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icy Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,W( 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> -'` <br /> Sanitary Permit Application State Tam on Num�/f(I v" <br /> In accordance with S.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a statuary permit. Note: Application forms for state-owned POW'fS are Project Address(if different than mailing address) �fV <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> u s in accordance with the Privacy Law,S.15.04(l m Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name /-! Parcel q <br /> L rd= iy0 / f Ca 3 j�� 0 7- 0-)S -�2 /fB/S�a�SOSOCbi- 9p� <br /> Property Owner's fling Address Property Location <br /> a so 2 sop Gov[ 3 <br /> .Lot <br /> _ <br /> City,State Zip Code Phone Number _�,_'A Section <br /> P, 1(_� /J �3 7� role one) <br /> II.Type of Building(check all that apply) 57 Lot q <br /> T Q N; R �`f E or� <br /> �I or 2 Family Dwelling-Number of Bedroom .L d-f Subdivision Name <br /> Block q <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ' 299 RTownof <br /> vo4 (o p �` <br /> IR.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. gNew stem ❑ Rlacement Sy eco System ❑TreatmenUHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Trunsfer to New List Previous Permit Number and Date Issued <br /> Before Ezpvation Owner' <br /> IV.Type ofPOWTSS stem/Com oent(Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?124 inof suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalfIrflestmeat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> • 7 6SU 90. so <br /> Vt.Tank Info Capacity in Total I q of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Pxiaiog Tasks � <br /> a 8 <br /> Septic or Holding Tank <br /> Dosing Chmiber /� [�v <br /> VII.Responsibility Statement- I,the undersigned,mum responsibility for installation of the POWTS shown on the attached plum <br /> Plumber's Name(Print) P bar's a MP/NWWRS Number Business Phone Number <br /> g�s4/'2I 715-W e7�3f� <br /> Plumber's Address(Street,City,State,ZipCode) <br /> P. &k 10'D // /� L GtJ�i if 7� <br /> V I.Conn /De rtment Use On <br /> proved ❑Disapproved Permit Fee Date Issued Issying Agent Signature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasoos for Disapproval <br /> Aaach to complete plans for are system and submit a the County ody m paper not las Mae 8 112 a 11 inches in da <br /> SBD-6398(R.10/11) <br />