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s�nsrit� �7 _ �/ <br /> t Safety and Buildings Division County G7 u r 17 1CTf <br /> 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \SPS`, Madison,WI 53707-7162 <br /> Sanitary Permit Application State Tr cbon NLm b <br /> In accordance with SPS 383.2 1(2),W is-Adm.Code,submission of this form to the appropriate governmental unit I) e <br /> 1 <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 /> Pit uses in accordance with the Privacv Law,s. 15.04(I Nm),Slats. / 3�f �fs�y /L <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> l r d-zoa 1{lO-/ledG`S'. . tW'50&Y 7C <br /> v1�r e ���l%<� S '),41 <br /> -690WD o2o•9/XJ <br /> Property Owner's Mailing Address Property Location <br /> ,+ 6d La„(c_ Cf- } d7r^. <br /> Govt.Lot <br /> City,State Zip Code Phone Number '/,, a 62 <br /> Section <br /> MaEA n -VI U't eW IM Al J*-j��� (circle one) <br /> 11.Type of Building(check all that a apply) Lot# T �{d N, R_/Eo� <br /> PP p <br /> KLI or 2 Farm ly D"el l ing-Number of Bedrooms Ip Subdivision e hName/ V1116fe of, I <br /> Block# q 4ke A5.w ala; PITT <br /> 111 Public/Commercial-Describe Use ❑ Ciry of <br /> ❑State Owned-Describe Use CSM Number El village of <br /> 9 Town of 0CFtClAnGQ- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> no_ y" <br /> A. ❑ New System Replacement System QTreatmen old me Tank Replacement Col ❑ Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal ❑ Permit Revision ❑Changof Plumber <br /> 11 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration - Owner <br /> 1N'.Type of POWTS Svstem/Com onent/Device: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inof suitable soil ❑ Mound<23 in,of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> N.Dispersal/Treatment.Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> NT Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units = S — <br /> t <br /> New Tanks Existing Tanks <br /> o _ <br /> Septic or Holding Tank 13-334 /333 $rb6 S/G,qw X <br /> Dosing Chamber <br /> x'11.Responsibilitv Statement- I,the undersigned,assume responsibility for installation of the POW'TS shown on the attached plans. <br /> Plumber s Name(Print) Plumber's SSiianaturree MRNIPRS Number Business Phone Number <br /> R? CIC �o IG/h 1 C�cG �T d;s6S"'"l �is�t'al/O —y/r2 <br /> Plumbers Address(Street,Crl,,State_Zip Code) <br /> -7760 14- ,l73-,5--- <br /> YII .County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> ry Date Issued Issuing ignature <br /> ❑Owner Given Reason for Denial $ 3�✓/ goel <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> " (��( 22 <br /> C'd •Eo ,131 oaeg Cu Ed dµ $ or BMA► qD l�liS�V <br /> kf+ (" H KLev. 939.70 /erE Com 6 b aCt,Arsw 95', 8¢ <br /> nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 uz x 11 i size <br /> UU <br /> BURNEITCOUW <br /> ssD-6398(R. 11/11) ZONING TY <br />