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County <br /> /✓ '' �'��,t Safety and Buildings Division Burn ,C <br /> DS 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS ? Madison,W1 53707-7162 \ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit jJ(Aq evlC <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 J <br /> purposes in accordance with the Pnvacv Law,s. 15.04(1 It m),Stats. ( scli o O h 01 le✓ f�A• <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# p-7-0AO-A4/0-/ -S <br /> '1'bk Cl'Q I�Yh I<!•1 Ya'TT '3 05-0 07 - bd.a OGO Zzaig,OcY 01N ) <br /> Property Owner's Mailing Address property Location <br /> / <br /> I 074 WBOeI9 De, Govt.Lot 7 <br /> City.State Zip Code Phone Number - <br /> `V,, Section <br /> IY7 / le one)- <br /> If.Type of Building(check all that apply) 2 Lot N T I/O N, R /� E <br /> 9,I or 2 Family Dwelling-Number of Bedrooms 7&O Subdivision Name <br /> Block 4 <br /> 0 Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of DG IC bf <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A <br /> ❑ New System Replacement System 7 CreutmenVHold ing Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision ❑Change of Plumber 11 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV'.Type of POWTS Systeriin Peden t/Dev ice: (Cheek all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in,ofsuitable soil <br /> XHulding Tank O Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalfrreatment.area Information: <br /> Design Flow(opd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3c <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units v <br /> u <br /> Vew Tanks Existing Tanks <br /> Septic or Holding Tank O—ed 3000 I ,Sew y/ x <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sicnature MP/MPRS Number Business Phone Number <br /> R/c,/C I-la p A-/a s / o ris1 pis-gG� —vis? <br /> Plumber's Address(Street,City.State-Zip Code) <br /> b1II.County/De artment Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuin se Signature <br /> ❑Owner Given Reason for Denial <br /> 3-15,40 . .2a <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> I / tans IYb(((icKc "5 D I /farfsF,af5- Gve4v0 { rW&L Ca.arp/9c. <br /> Ji4x it fhd((.atQ 46 k put sI. {a.e. Zone.A FLoa ?Jail :t on JJ.. FIRM Io/ Awne- ' y 1105x1 4) M"&06. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 V21 11 inches in sae <br /> SBD-6398(R. 11/11) <br />