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County <br /> Safety and Buildings Division <br /> ( + Q$P ,,..(;# 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> S Madison,WI 53707-7162 <br /> t \ <br /> ` � 5589b� <br /> Sanitary permit Application State Tr nsa//ctio/nNumber <br /> In accordance with SPS 3812 1(2),W is.Adm.Code,submission of this form to the appropriate governmental unit T 7 A%,, <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(1 Xm),Stats. dpys'N. R1, e 4a le. 'Fa <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name I/ Parcel# <br /> JD�n $Kefe ff 070� 4a13S1IIVOSwro Soa14- <br /> 777111A2n I CApW 10:024-6110-04-210) OA 3/00 <br /> Property Owner's Mailing Address Property Location <br /> 3S 7 R C• Co t0 Y1-•F'/ Grh `e Govt.Lot 7 <br /> City,State Zip Code Phone Number Section /O <br /> lbvk, l-e l�Pp,�. ��<r 5,5-/I o (circle one) <br /> It.Type of Building(check all that apply) Lot# T 3y N; R /4 Eo <br /> r9 <br /> PP Y) <br /> I&I or 2 Family Dwelling-Number of Bedrooms d Z Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number 357/ob.B El Village of <br /> Er Town of /?45 k <br /> ✓off. Iq 0 e. fIFO <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A <br /> ❑ New System Replacement System 'Treatment/Holding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Dare Issued <br /> Before Expiration Owner <br /> IN.Type of POWTS Svstem/Com onent/Device: Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 124 inof suitable soil 0 Mound<24 in.of suitable soil <br /> Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersalfrreatment.Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 360 — — -- <br /> VI.Tank Info Capacity in Total ftor Manufacturer <br /> Gallons Gallons Units v - <br /> IsewTsnks Existing Tanks <br /> - U tAr L <br /> Septic or Holding Tank W'Is-Ge -Q$ rr <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature tiIPiMPRS Number Business Phone Number <br /> /tic/e- /te &,. t / ddsssl lis-86G - 4-1/s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> SV111)77inO X/w y X,!;-- <br /> V111. <br /> .County/De artment Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing Age -_nature <br /> g 375 /3ld <br /> ❑ Owner Given Reason for Denial , QUA 2.6i <br /> IS.Conditions of Approval/Reasons for Disapproval <br /> 'it-Imirw Vaw Ava,14n- n. C0W&* 'k swS�wt 5'6kal'6we, J14Ewc �.+./d/A+.t GrW�r ve upyrs tur�s�.t aAs• <br /> SIL' is net adic-444 t„ it -J,",r, kA- AE Al000t?lu3 of l Ica <br /> Attach incomplete plans for the system and submit to the County only on paper not less than 8 112 s 11 inches in size <br /> SBD-6398(R. 11/11) <br />