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„rtes h County <br /> z �.y qtq Safety and Buildings Division <br /> $ S 201 W.Washington Ave.,P.O.Box 7162 Sani ary Permit Number(to be filled in by Co.) <br /> p^+ Madison,WI 53707-7162 <br /> 54 852 U <br /> Sanitary Permit Application State Trumee en Number <br /> In accomanee with SPS 383.21(2), Wis.Adm.Cade.submission of No form ro the appropriate govermaxamal <br /> unit is rrquird prior to obaining a sanitary, permit. Note: Application forms for scueowned POWTS are Project Address(if different than mailing address) <br /> submmed m the Department of Safety ad Professional Soria. Pe rmoal information you provide may be used <br /> for secourfer,purposes in accordance whh We Privacy Law,s. 15. 1)ra,Sm <br /> I. Application Information-Please Print All Information 231c5' 6 l of 3 <br /> Property Owrrer's Name Parcel p e5 <br /> o'74, -2-38 -i3-2 Aadev <br /> Property Owner's Me fling Address Property Location <br /> 19' 2 3S Glete, �'Qc AV C Gon.IA[ I <br /> City.Stale Zip Code Fhme Number y, a'seemm -56, <br /> fake %//CIWIIAI, 3'sov5' 7 "Eos' <br /> II.Type of Building(check all that apply) Inc d N; R <br /> 2h or 2 Family Dwelling-Number of Bedrooms Y Subdivision Name <br /> Block; <br /> ❑Public/Commereial-Describe Use ❑ City of <br /> 0 Sum Owtled-Describe Use CSM Number Cl Village of <br /> /7l ❑ Townaf 03,<!/S <br /> 111.Type of Permit: (Check only one box on Woe A. Complete Bne B If applicable) <br /> A' ES,;- Replacement System ❑Tresucarmolding Tank Replacement Only 0 Other Modification m Existing Sysrem(explain) <br /> B. 0 Permi[Revision ❑ Climatic of 0 Fermat Trnsfer to New List Previous Fermat Number ad Dae Issued <br /> Plumber Owner <br /> W.Type of POUTS S m/Com nent/Device: (Cheek all that appW <br /> 0 Non-Pressurird In .to and 0 Pressurized In- mud 0 At-Grade 0 Moud> 24 in.of suitable it 0 Moud a 24 in, d ud aw,mil <br /> Ia Holding Tank: 0 Ca ar Dispersal Component(eaplaim 0 pretreatment Device(explain) <br /> V. rsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rau(gpds0 Dispersal Ara Required(at) Dispersal Area Proposed(s0 System Elevation <br /> J-13!,ysfl 1 _ _ _ <br /> VI.Tank Info Capacity in Total F of Marwfacmra <br /> Gaiters Gallons Itemsc `$ <br /> New Tanks @meta,Tanks <br /> SU V i <br /> Srglc or Balding Tank 20m 2� / fu: er Cvnc X <br /> Imeia Ouneer <br /> VII.Responsibikty Statement- 1,We undersigned,assume respos i ilily for InnaRation of the POUTS shone ou the anachd plays. <br /> Plumber's Name(Frio p Plu s S'g MP/MPRs Number Busmas Ptmrm Needier,7� /sen /•3.5"6SS 7l/,5' (.r17—?sac <br /> Plumber's Address(Street . <br /> City,State.Zip Cade) <br /> 33"72 sT <br /> VIII.County/Department Use Only <br /> APprovd 0 Disapproved Permit Pee Desk I ani sset Iscat Signature <br /> $ 3 l0 3 <br /> ❑ Owrsr Given Reason for Denial <br /> IX.Conditions of Approval/Reasmes for Disapproval <br /> Artnch w complete phm for We alsmem and wbear to be County only an Aper art Ins true 3 ma x 11 inches W also <br />