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+/slyTr'r+�y' County <br /> Safety and Buildings Division Jtw r.1 077' <br /> D$ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \ PS' Madison,WI 53707-7162 <br /> Sanitary Permit Application state Trans tonNumber <br /> In accordance with SPS 383 2](2),Wis-Adm.Code,submission of[his form to the appropriate governmental unitgPi y rsCVECr.V <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 <br /> u ses in accordance with the Privacy Law,s 15.04(1 Xri Stars_ D PWA 1. Application Information-Please Print All Information .2909/ Allow River 60' A <br /> Property Owner's Name 1 Parcel# =7.Oa.0- -� -O7 5 <br /> Uru.Gr- Alor,s,fre..1 � _ /"!� /S-SW - V1 :7` (900 <br /> Pro//perty Owner's Mailing Address' Property Location :020.9/,f5'DI.1700 <br /> A qO q� E Y�e l4ow /�r0�✓ � Govt Lot <br /> City,State Zip Code Phone Number y y,, Section 7 <br /> /Detnb µn y LVT ✓Ki83o T y� N. (circle <br /> If.Type of Building(check all that apply) Lot# <br /> 90 I ort Family Dwelling-Number of Bedrooms 4s Subdivision Name <br /> Block# Po UYI�s IUer 1.��i <br /> 163 <br /> EIPublic/Commercial-Describe Use <br /> ❑ City of <br /> Number D Village of State Owned-Describe Use CSM N - <br /> ,'Townot' Gia 11 , e- <br /> IT.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. <br /> ❑ New System p6 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modi[icanon to Existing System(explain) <br /> B. D Permit Renewal /❑ 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 POVV'TS Svstem/Com onent/Deviee: (Check all that apply) <br /> YN on-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 inofsuitable soil D Mound,24 inofsuitable soil <br /> D Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(opcist) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 36a 1 7 y 9 d1 si. vo <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> _ <br /> Septic or Holding Tank 7 01 ;> <br /> Dosing Chmnbcr ,roe) X7..4 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW'TS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /2,G/C- Wo k-t.1 12_-,1 .sO <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of 77611 k1-Pk,, <br /> V111.Couatv/De artment L`se On I <br /> J Approved D Disapproved Permit FeeppJ��� Date Issued Issuing Age _ ature <br /> $ <br /> D Owner Given Reason for Denial 3,26 SAD //�V �jjjl <br /> It.Conditions of Approval/Reasons for Disapproval <br /> Attach incomplete plans for the system and submit to the County only on paper not less than 8 t2 s 11 inches in size <br /> SBD-6398(R. 11/11) <br />