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County <br /> Safety and Buildings Division Wi C1 I'A.) Fa� <br /> i 0 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> a� ^fir Madison,WI 53707-7162 <br /> log.� <br /> Sanitary Permit Application state Tr tion Number <br /> In accordance with SPS 353.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ...� � <br /> to required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted w Project Address(ifdifferent than n fling address) <br /> the Department of Safety and Professional Sc"iC$. Personal information you provide may be used for secondary <br /> u oses in accordance with the Privac Law,s.15.04 I m,Stats. l <br /> I. lOwn.n Information <br /> Property Own. -Please Print All Information Q�3 t f e- / lSC 4 r6.5 <br /> r's Name <br /> r t <br /> e / c 3� '02 07 <br /> Property Owner' ailing Address - - -J'j- -o i <br /> 2 -Z /O Property Location <br /> J c- (� e /J <br /> City,State Zi Code Govt.Lot <br /> , L P Phone Number <br /> O r'o` L, 1C 5 9C '' ��U 4dY., Section <br /> e SSo a 6�/-5 03-9/Y7 ?? FC7 (circle one <br /> II.Type of Building(check all that apply) ��'77 Lot# T--rL N. R / 7 E e W� <br /> Y-Lor2 Family Dwelling-Number of Bedrooms 2 —_3 _ Subdivision Name <br /> „_ <br /> ❑Public/Commercial-Describe Use Block# <br /> r ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 1 9Town of d)ejAt)ie� �S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A• Ipt.New System Y El Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration g ❑Permit Transfer to New <br /> Owner <br /> IV.Type of POWTS S stem/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Molding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treat cnjArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Exisliag Tanks w v U � <br /> a. U in y w C7 P, <br /> Septic.or Holding Tank 07—/006) '— OO() C L •� <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS NumberBusiness Phone Number <br /> 1 fit. N �S �c✓.� � �.� :Zz7 6 y� �v y -7�z �c <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IR d x S/ S "/ e_e.) 6-0-F S/f 7-2 <br /> VIII.Count /De artment Use Ont <br /> ❑Approved ❑Disapproved Permit Feel Date Issued Issuing Signature <br /> ❑ Owner Given Reason for Denial 37sSx� )3 Av, ?o/Z <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ATIZ: VaIrlaNGG � A414 f' IdNK AQQI kXd r 4t 9-r USC. e45, <br /> 2 1Wd Gtllww iaares Sa£• i< kufie fav can itvStrw ?c A(a.r( rew. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in size <br /> SBD-6398(R. I1/I1) <br />