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LaC7� vj, County <br /> f t Safety and Buildings Division i <br /> ® 'Tr 201 W.Washington Ave., P.O. Box 1162 Sanitary Permit Number(to be filled in by Co.) <br /> \ P$ ! Madison,WI 53707-7162 <br /> ,1�W SSBI18 <br /> Sanitary Permit Application State Tr ion Numbber, CI <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit ( � j�evlrr� <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) ,., 1 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary xJ <br /> purposesin accordance with the Privacy Law,s. 15.04(1 m),Stats. ,x �� <br /> 1. Application Information-Please Print All Information f/s+� 5, YI r` <br /> Property Owner's N e Parcel#07-0/3-2-2-47-4-03-5 05A03 <br /> e d, �� w 0183 56 3011960 lu� <br /> Property <br /> �/Owner's ailing Address Property Location <br /> -f , e,ot /VU6 c Govt.Lot_,13 <br /> City,State Zip Code Phone Number <br /> fir '/4, <br /> G�if/� �� /., /., Section <br /> ��� � � (chole one <br /> 11.Type o Building(check all that apply) Lot# T _N; R E o <br /> XI or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑CiTy of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of Wet w^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 /> ) <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 /> ❑Non-Pressurized In-Ground ❑ Pressurized In-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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> c <br /> sU v <br /> New Tanks Existing Tanks v`O. � v n <br /> a U � V <br /> Septic or Holding Tank aV <br /> Vki <br /> Dosing Chamber �V <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Print) Plum r' SignatureZ MP/MPRs Number Business Phone Number <br /> o l er /95-J 5 / <br /> Plumber's Address(Street,City,State,ZipC ) <br /> � (NcLsr�erw;541�g <br /> VII Count Department Use Onl <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing ig^ature <br /> El Owner Given Reason for Denial $375 �iru /2 J rel �2 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 6(fX /5 ,bl,e( t•fdV( e4 /4'm Zr F1W.0e11du) cf L)CU;1J`,Z(AI®e- <br /> 04 -66e FRM 1r3rne* Covmty ,adkojaft /9, 1ad/ RD <br /> E <br /> nME <br /> a 7017 <br /> JUL Y <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 i <br /> Ltj <br /> BURNM CwNw <br /> SBD-6398(R. 11/11) ZONING <br />