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dor v <br /> Conrnorce.WI.g0v Safety and Buildings Division —county <br /> 201 W.Washington Ave.,P.O.Box 7162 691 In v{j <br /> i sco n s n Madison wl 53707-7162 Sanitary Perm' Nanaba m be fated in by Co.) <br /> ta.penww.rwo<Cormw.ru. g <br /> Sanitary Permit Application Stab TnmaaOon Number <br /> In accordance with s.Conor.3321(2),Wit.Adm.Code,submiaioa of thio fetal to the appropriate govemmeaal �f(� �J <br /> mit h required prier to obh®ing a sanitary permit Note: Application fo. for aWt ..nod POWTS aroact <br /> Proj Addnne(ri'differem than maaing address) <br /> submdtd to the D ce with t of Commerce. Peraomt mfomvtion you provide my h and for secondary <br /> in <br /> accordance with the Priv Law,s.15. 1 m Stats. <br /> L A Bntioa lnfmrmatlmt-Please Print Ag hdormati m 3 D bei(, J.,AA so n <br /> Propaty Owner's Neale I 1.1 <br /> Parcel# l/ <br /> 1114ref JGeehy 03} ..S`404.- p/apb <br /> Property Owns a Madmg Addma Property Location <br /> A// / yr/pn s✓ /�vC Govtlat <br /> City,Stab Ztp Code Phone Nmbr Y., Yy SccOon J fl <br /> M'v <br /> IL Type of Building(cheek all that appl3') Lot 0 6Se- ss 49 T c/) N: R /S E <br /> ®1 a 2 Family Dwelling-Nrmber of Bedrooms : I Subdi oar area <br /> ❑PubtldCoauner- l- Block# - <br /> Ileam'beU.e <br /> ❑City of <br /> ❑State Owmd-I)..be Use CSM/Number ❑vahge of. <br /> Y s 5. a QS OrTown of Seg-a ✓J <br /> "L Type of Pernik (Check only oke bon oar lake A. Complete line B if appiimble)11 <br /> ❑New System Rephctmwt <br /> Sysbm ❑TkenmmVHoldiag TaskRephcemwt Onty LOO—d- <br /> Before <br /> Modification b Faiatmg System(eaphm) <br /> B. ❑Pam@Rwewal ❑Pamrt Rwhion ❑ChangeofPlumba ❑pFam6 Tramferm New List reviom&WmitNand Dathaoed <br /> Papvahon Owns <br /> IV. of POWTS S stem/Com ent/Devke: Check all that apply) <br /> C No Pane coed la-C—und ❑P'msurined In-Geouod ❑At-Grade ❑Mo md>2A iv.of surtabb soar ❑Mond<2q io.of suitable soar <br /> ❑Holdmg Tm* ❑Otha Dwperad ConW oar(cxPb-) - ❑1'retrumtwtDovim <br /> (explain) <br /> V. al/1'reatatatt Area Information: <br /> Design Flow(gpd) Design Soa ApPlimtion Rate(gpdet) Dhpersal Area Required(at) Du <br /> uS19 pawl Amar Proposed(et) System F,Imtion <br /> VL Tank Into l0 4r3 <br /> C+ParitY m Total #of MamLctma <br /> Ganom Gallon Unit <br /> 0 <br /> New 7anb <br /> nambgTudu <br /> Septic a ltolduq Tank SCI a CT i� <br /> Drmig Clwmlur <br /> VII.Respamibility Statement-1,the undersigned,mume ropansibility for intstietion of the POWTS shown m the attached plena <br /> Phmba'a Nam(Print) Plumber's Signatum MPM1Plt3 Number Brstam Phone Number <br /> �rn1715-866- 4/S7 <br /> Phm6er's Aileron(Srsaer,city.State,Zip Code) <br /> � 7760 t.v 3S U/E617°P� w1 Se16'9� <br /> L Coan armtent Ux Ord <br /> ❑INsappmved Permit Fare/�f� Dab tanned lauhg as Sigsahue <br /> ❑Qarner cirwReaon for Denial <br /> S '"`� 5-13-0 <br /> Lr.C,6"tiom of ApprovaUReaemn far Dhappsoval <br /> Aataeh b real phde Phe aw do gees ad enhai tithe"only adyen papa moa then 3 in a 11 laches Y dos <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />