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�nrrt�K <br /> County <br /> Safety and Buildings Division /3k r-K.ef( <br /> 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \ P <br /> Madison,WI 53707-7162 <br /> t' j588 75 <br /> Sanitary Permit Application State Tr tion Number <br /> In accordance with SPS 383 2](2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �7 '`nv e�d <br /> is required prior to obtaining a sanitary permit. Noce.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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1 Yoh).Stats- <br /> 1. Application Information-Please Print.all Information <br /> Property Owners Name // Parcel# D7-p/2.1-1/p-IS•/G-S C6-�"01200 <br /> a eS CraS.Str^ 62,4_,351DD��-�l�l(a- 07 SOp <br /> Property Owner's Mailing Address Property Location <br /> / 3 /u $t� La < N tti Govt Lot �o <br /> City.State Zip Code Phone Number /., Section ( (a <br /> lgp%�OfZC✓ 1-n Al 5.r3� (circle one) <br /> �11}.Type of Building(check all that apply) Lot# T 4 N, R _E o® <br /> /tel I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> D Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of J<C k'se h <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> \. <br /> ❑ New System El Replacement System XTreatmenV _ ❑ Other Modification to Existing System(explain) <br /> R-C /C G a 7f -- <br /> B. <br /> B. D Permit Renewal D Permit Revision ❑ Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of PONNTS System/Component/Device: Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound 124 inof suitable soil D Mound<24 inof suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V. Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 30e — — — <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 8 V <br /> New Tanks Existing Tanks <br /> 5eptic or Holding Tank —7 S--v 7S-0 t (-t-t-e d'Y✓ <br /> Dosing Chamber <br /> VI 1. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POVVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's'Si-gnattuure NIP/MPRS Number Business Phone Number <br /> I t.�C l�l0 /e 1" .3 /G�G�-.X a�S�S/ �.S 5F6,eO- ey Zs 7 <br /> Plumbers Address(Street, ny,State,Zip Code) <br /> ',-77&d w 3S w �bs>`Yi wy� S'f�53 <br /> . <br /> VII Coun tv/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing nt Signature <br /> $ <br /> ,3z5� zs i2 <br /> ❑ Owner Given Reason tar Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 410('a4r. j5klsEu+' 5zp,� iahK r Allow Fr �hlpofu <br /> Miffed es 3 F4 8 G S�ret(u.,l oar„y Sam <br /> Attach to complete plans for the sJ9rem and submit to the County only on paper not less than 8 Uz s It inches in size <br /> SBD-6398(R. I I/1I) <br />