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Safety and Buildings Division Cour r� <br /> f 201 W.Washington Ave.,P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> j Madison,WI 53707-7162 <br /> Sanitary Permit Application State Tr nssaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit z6 14J, <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if diffqrent 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. I m,Stats. ��,�� ss A _I i llT <br /> I. A lication Information-Please Print All Information IC u 7( <br /> Property Owner's Name Parcel# <br /> �fEh4- „ d� -03'1--.2-37419 -/ <br /> il CV-0 6G-t7/// <br /> Proyp/eerrly Owner's Mailing Address Property Location <br /> Govt.Lot / <br /> City,State � /,�^ Zip Code 01 Phone Number y ^ ['' �A 1�� y,, Section l <br /> C I � ` <br /> ✓ r-+ ' �66 ^ 7 17+ .2 6 J 3 r7 J T__ ZN; R (circle one <br /> I1.Type of Building(check all that apply) Lot# e Eor(V <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms 2- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> El State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> V <br /> 2n Townof ✓rq >t �"c 1, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑ Change of Plumber E01 it Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent/Device: Check aB that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil KMound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Disficirsunrcatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Etc ion <br /> 0o r � 366 neo /63, 6 7 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks c Vex a <br /> a+ U cis moo, w C7 P-i <br /> Septic or Holding Tank 70-0 0 Itqo t r) ca V, \� <br /> losing Chamber 7� 7�t% / W).1 I C &-- <br /> VH. <br /> VII.Res nsibil Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name ' t) l Plumber's Si -- MP/MPRS Number usiness P one Number <br /> GE✓' � �rhilfl a�aV60 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ag3G We Wexx,� kav WL <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved PermitFeeDate Issued Issuing Agent Signature <br /> IJOwner Given Reason for Denial $ J / (�9"'�� L& <br /> UL Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plain for the system and winnit to the County only on paper not less than 8 in x I l inches in size <br /> SBD-6398(R. I I/11) <br />