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r�;3a ie:y� County <br /> <' * Safety and Buildings Division V <br /> D S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P s � Madison,WI 53707-7162 rT)C1 r/a- <br /> ,1525 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission;!this form to the appropriate governmental unit <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 /> purposes in accordance with the Privacy Law,s.15.04 I)(m),Stats. 3G A241. Application Information-Please Print AD Information <br /> Property Owners Name Parcel# <br /> Ca la01 .&.Yv.ya-rf-v of-dot-o lidw <br /> Property <br /> Owneirs Mailing Ad ss Property Location <br /> /`g� ( • Ic Govt Lot <br /> City,State /� Zip Code Phones Number %4, Section <br /> (�{.- Ob�/ q�(3"G 7��2✓Z T 7d N; R �f�circlE o <br /> 11.Type of Building(check a that apply) Let# <br /> �1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of L <br /> V nfi VTownof 7Qf <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. ❑New System R Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑Change of PlumberList Previous Permit Number and Date Issued <br /> g FEJrmitTransfer to NewBefore Expiration er <br /> -a 7 S <br /> 1V.Type of POWTS S tem/Com onent(Device: (Check all that appW) r. At-Y12 4LF <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 is of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6k 8 93, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units =' ccU <br /> Nero Tanks Existing Tanks u`: c Utio `v h <br /> q rp <br /> as U "vr q yr io V a <br /> Septic or Holding Tank 12-00 sA0 <br /> Dosing Chamber Z <br /> VIT.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) /` Plumbeignature MPiMPRS Number Business Phone Number <br /> 05� Dr! nit ems- % 851`lS -i5-56f�-O2o z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7-7Z00 -Tair,t�.JA if, 5'�tBP <br /> VIII.County/Department Use Only <br /> Approved 1 ❑Disapproved Permit Fee Date Issued / Issuing Agent Signature <br /> ❑Owner Given Reason for Denial 4 �'D <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> Atlach to complete plans for the system and submit to the County only on paper not less than a W z I t inches in size <br /> SBD-6398(R. 1 Ill]) <br />