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pgpA0.T3t <br /> b�2 en Comm � <br /> Safety and Buildings Division cz/,N <br /> e 741 <br /> p 1 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) (, <br /> Madison,WI 53707-7162 W <br /> � A <br /> 56129 7 <br /> Sanitary Permit Application State Transaction Nnmber _ <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit vf6 y e V I cl:to <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted no 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 m,Stats. -24,97Z <br /> 4 972 4d <br /> I. Application Information-Please Print All Information C !/l 6 w <br /> Property 9 <br /> wner's Name Parcel q OgrSO 9 5 <br /> SI iz_ /VetiAJ / C- fCP__ 6,A 05— ooS— 0/ 700o <br /> Property Owner's Mailing Address yu� L - Property Location /> c/ <br /> /0I SC O!'1' CI , Govt.Lot <br /> City,State Zip Code/'? TN; REorb <br /> Phone Number ''/a, Section <br /> C P(' A" �'/" 3 q7 / Lcircle one <br /> II.Type of Building(check all that apply) Lot# <br /> ,or 2 Family Dwelling-Number of Bedrooms ! Subdivision Name <br /> _ Block# <br /> ❑Public/Commercial-Describe Use -�^ <br /> ❑ City of <br /> El State Owned-Describe Use CSM Number El Village of <br /> V 6 p a s`� mwm of Z_ O e e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) Q O _Q <br /> A. ' ,New System ys ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> kNon-Pressurized In-Ground ❑Pressurized En-Ground ❑At-Grade ❑ Mound>24 in,of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3ov , <br /> 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ,9, u <br /> New Tanks Existing Tenks .° as �` <br /> Septic ori 7s n 76-6 <br /> �- <br /> Dosing Chamber V <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 Number Business Phone Number <br /> Zz769Y <br /> Plumber's Address(Street,City,State,ZR Code) <br /> ,Q 0 i _-9 e- <br /> VIIL County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Daate-Issssued Issuin t Signature <br /> ❑Owner Given Reason for Denial $ 6z 8�J un ZO/Z <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Soil kta(4 tndtce6cs 7,Z( B - 5/65R6aw X )oaurY 5&wA D <br /> JUN 8 2012 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1rz 1 hes in size <br /> 13URNETTCOUNTY <br /> ZONING <br /> SBD-6398(R. 11/11) <br />