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/d5"�nitM1 County <br /> Safety and Buildings Division u rv1 e ff <br /> D$ r� 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Cc <br /> p$ Madison,WI 53707-7162 <br /> Sanitary Pelnll(t Application StateTra a 1nNumble(q'p'1 <br /> In accordance with SPS 38321(2),W is.Adm.Code,submission of 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- 15.011)(m),Stats. l 4as <br /> I. Application Information-Please Print.all Information L <br /> Property Owner's Name Parcel p7.Od0-d•NOI •O •S. <br /> �lituC SCO/7 rt't /s_,A(aa- 0f70,9p <br /> Property O%ner's Mailing Address ,AProperty Location <br /> 4.( 309 //Ao,('e •f .4, Al Govt Lot q <br /> City,State Zip Code Phone Number y,, /,, Section Ot <br /> QA& 01H g (circle one) <br /> 11.Type of Building(check all that apply)I Lot# T !IO N; R 16 E or(V <br /> 77 <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block« U ,fake <br /> ❑ Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ry0 Village of <br /> CITONnot CV41elAnW <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) — <br /> ❑ New System Replacement System 0 TreatmenbHolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> B. 11 Permit Renewal ❑ Permit Revision ❑Permit Transfer[o New <br /> Before Expiration Owner <br /> ,,1�%,/l..�Tv a of PONVTS System/Com onent/Dev ice: (Check all that a Iv) <br /> �ANon-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 inof suitable soil ❑ Mound<2y inof suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> —'?m0 . 7 4/B(I <br /> VI.Tank Info Capacity in Total k of Manuf cturer <br /> Gallons Gallons Units - c <br /> New Tanks Existing Tanks �,, °-' - <br /> Septic or Holdine Tank 205--0 ApsO _41 tit 11,OA <br /> Dosing Chamber <br /> VI I. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PON TS shown on the attached plans. <br /> Plumber's Name(Print'))// Plumber s Signature MP/MPRS Number Business Phone Number <br /> 421,LIG /7`O 1G z„ S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 /s! Gv-e b s7Y. L4/:7— S 5_T9 3 <br /> V 111.County/Department Cse Only <br /> Approved 11 Disapproved Permit Fee Date Issued Issuin_s Age ic ire <br /> El Owner Given Reason for Denial <br /> // <br /> r7 <br /> of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County,only on paper not less than 8 VE x 11 inches in size <br /> SBD-6398(R. 11/11) <br />