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cORlmerce.Wl yOV Safety and Buildings Division County <br /> �+m 201 W.Washington Ave.,P.O.Box 7162 v <br /> S Co n S i n Madison,Wl 53707-7162 SanitayliantitNumbet(to be filled in by Co.) <br /> tiivemb"Molcommeron <br /> 6 / b l9 <br /> Sanitary Permit Application State Tmnaxtion Numbo <br /> In accordance with a Comm.83.21(2),Vis.Adm.Code,submission of this form to the appropriate govemntentd --V ' <br /> mit is requited pia to obtaining a salutary, permit Note Application forms for stseeawned pOWTS ate Pmjea Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you protide may be used for secondary <br /> purposes in accordance with the Privacy I.aw s.15. ! m Stats. <br /> L Application Information—Plum Print AD Information <br /> Property Owner's Name Patel# <br /> G Y l ' 4 o0 2/33 L>2-100wner <br /> Property OMailing Address Property Location <br /> 633 D t-� A LI'. con.Lot AJA _ <br /> City,State Zip <br /> tCode Phone Numbs ty S v Y..�Y.., Section -)Z <br /> �CWIl b s /E3 T 3� (circle Mi <br /> N, REm <br /> IL Type of Building(check all that apply) Lot# <br /> ,W I or2Family DwcEiag-NumhwofBWmms 2 AIA Subdivision Nate <br /> Block# h <br /> ❑PubRdCommocial-Describe Use <br /> //A ❑City of <br /> ❑State Owned-Describe Use CSMNumba ❑Village of <br /> 111A <br /> 12 Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B U applicable) <br /> A' JW New System ❑Replacement System ❑Ttestment/HoldmgTadt Replocemeat Only ❑OtherModifiatim to Esisting System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Changeofpltmber ❑Permit ThnsRno New ListPrcvioa permit Number and Date Issued <br /> Before Expaimm t>Wner . <br /> IV.T e of POWTS S Com neitVDevice: Cheek all that apply) <br /> NoaPrasmized In-Grotmd ❑pressurized Io-Omand ❑At-Grade ❑Mound a 24 m.ofaintable m0 ❑Mound<24 m-of suitablesoil <br /> ❑Holding Tads ❑0dw DiapecW Cougmonmt(a Pl=) ❑Prcheaoment Devine(=ph=) <br /> V.DispeirsaVrreatment Area Information: <br /> Design Flow(zA Design Soil Application Rate(gpdsf) Different Area Required(af) Disposal Am Proposed(at) System Elevarim <br /> V 7 ctrl . S 6 ` — 906 E/S/i 9/G o . bo <br /> VL Tank Info 'ty in Total #of Manufiemer <br /> Galloon I Gallus Units S c� o <br /> Hew Todu Existing Tants Y. o 3 <br /> Septic"Hotdiog Talc 06 <br /> DuringOunni" 7 6 <br /> VII.Responsibility Statement-I,the anderdgned,assume responsibility for Installation of the:POWTS shown on the attached plans. <br /> Phunba•s Name(Print) Plumbs s Signature WWRS Number Business Phone Number <br /> 223337 <br /> Plumbe•s Address;(Sweet,City,Shrlc Zip Code) <br /> o ani S 8 3 <br /> VIII.County/Department Use Only <br /> Approved I ❑DisapprovedPermit Fee Dote Issued Issuing <br /> ❑Owner Givm Reason for Denial S 300 <br /> DL Conditions of ApprovallReasons for Disapproval ^ <br /> (-L�VA\vj <br /> MAY 1 2 2008 �I <br /> Attach toeomp&rspiaos forth@sysimasd submit to the Comity**=papa malosthan gin ill tc Y ETT COUNTY <br /> 6V ZONING <br /> SBD-6398 aL 01/07)Valid than 01/09 <br />