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Safety and Buildings Division County p <br /> 201 W.Washington Ave,P.O.Box 7162 f?k r 0 f�— <br /> ►sconsm Madison,WI 53707-7162 Sanita ;; Number(m be filled in by Co.) <br /> Department Of Commerce (hog)266-3151 (� e/� Y <br /> Sanitary Permit Application State Pin LO'Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal infcourrion you provide <br /> may W used for secondary,purposes Privaeylaw,sIS M(lXm) Project Add,ess(if deferent than mailing address) <br /> 1. Application Information-Please Print All Information 3 ys S6 M&//a Gia <br /> Property Owna's Name parcel4 Ut# elockd <br /> R~/a Cop kl—k 01 11 <br /> 4tt)•/ o,l 700 <br /> Property Owner's Mailing Address Praperty Location <br /> Al a'/sa 970,,A 5. vrt. Lora. <br /> Ciry,State Zip Cotle Plane Number V., A, Section }aia <br /> rdenawA)N; R / E <br /> II.Type of Ruilding(check all that apply) T YD <br /> IM I ort Family Dwelling-NumbmofBedrooms 3 Subdiviom1bll/ame CSM Norther❑Public/Commercial-Describe Use e6 V, <br /> ❑Spate Owned-Describe Use ❑Ciry_DVnEgr AFim^rshipof .f Z*S, <br /> III.Type of Permit (Cheek only one box an line A. Complete line B ifapplicable) <br /> mI <br /> A_ New Syswm ❑Replacemcn[gyssem ❑TreatmmtMolding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permitftenewal ❑Permit Revision Cl Chou of ❑Permit Transfer to New List Previous PentioNumber and Date ISSUN <br /> Before Expiration Plumber Owner <br /> TV.Type of POWTSS stem: Cheekall that apply) <br /> ®Non-Pressmimi lin-Ground ❑hound>24 in.of suitable soil ❑Mouad e N in.afsuitible soil ❑At Gmde ❑Single Pairs Sand Filter ❑ <br /> Censtmeted Welland ❑Pressurized In-Ground ❑Holding Tank ❑Pon(Filter ❑Aemblc I=Meet Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Symhmm Medi"Filter ❑Loathing Chamfer ❑Drip Line ❑Gravel-less Pipe ❑(hher(explain) <br /> V.Dix eraaVrrealnnam Area lnforma krou <br /> D <br /> Design Flaw(gpd) Design Soil Application RstIXBpdst) ispersalAme Required(sQ Dispersal Area Proposed(sQ System F,leve[ion <br /> 4.s'49 1 • 7 1 r,'/.3 6y8 9iP. 7or, <br /> 9a-3 <br /> VL Tank Info Capacity in 'me' hNum�r Manufacturer Prefab Site Steel Filer Plastc <br /> Gallas Cannot Concrete Castmmed GlazsNew gni"anTgTater' Tvi4sSeMic^r N^ItlinN Tan4 �aad /OOa <br /> Aerobic Toximenthis <br /> Doai ,fWmbee <br /> V IL Responsibility Statement- L the undenigned,assunre respensibilily for inslallaliun of the POW I S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPIMPRS Number Business Phone Number <br /> Ire/e //a /e,., S S"95-1 ?'/s- 9T 6-oi` 7 <br /> Plumber's Adores%(Somal Ciry,Stale,Zip Code) <br /> ot 7'76 /Zr, 3s'" we.bs>t pv wy Se/�4J <br /> V I.Coon /De artment Use Onl <br /> Approved ❑Disapproved Spnrtmy Permit Fee(Includes Groundwater Date homes Iss Agent Sl ore(Nn Scamps) <br /> gurcler8e Fee) -I <br /> eni <br /> ❑OwncrGivenReasonforDal Js1 I V alp <br /> M.Conditions of Approval/Reasons for Disapproval <br /> Areas oompk4 plan on Me Coonry orly)for the storm on paper not Inc than ala a 11 inches to sire <br /> SBD-6398(R.01/03) <br />