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-: if County <br /> Safety and Buildings Division J_?q H^--f ft- <br /> ;$f, D �� 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> Bsps; � Madison,Wl 53707-7162 <br /> Sanitary Permit Application StateTr ctionNum er <br /> In accordance with SPS 383.21(2).Wis.Adm.Code,submission of this form to the appropriate governmental unit bw�.'t V1 C6t) <br /> is required prior to obtaining a sanitary permit. Note.Application fortes for state-owned POW-FS are submitted to 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(IHm).Slats. s <br /> 1. Application Information-Please Print All Information x7608 Peel,Y Or <br /> Property Owner's Name t Parcel# p7-O fd•e(-YOBS-a 7:5. <br /> Jo-el M0.101AAll-I � 655. 00x- 0,99000 <br /> Property Owner's Mailing Address Property Location 4AJ&cY 1 0)2-4127-0-WO <br /> `1707 S. Govt Lot a <br /> City,State Zip Code Phone Number y, /,, Section tik7 <br /> (circle one) <br /> I3t9lei t IAJZ S3.r/1 <br /> LType Building Lot TSN; R �Eor�e <br /> yp g(check all that apply) n <br /> I or 2 Family Dwelling-Number of Bedrooms ✓'s Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> 52 Town of Jac-kse <br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System �Replacement System ❑TreatmenVHolding Tank Replacement Only [I Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of P0N4'TS System/Com onent/Device: (Check all[hat a Iv) <br /> ,k Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil 0 Mound<24 inof suitable soil <br /> O Holding Tank O Other Dispersal Component(explain) O Pretreatment Device(explain) <br /> V. Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ? tid 5 `Y3d /. /0 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � 'v <br /> _ <br /> New Tanks Existing Tants u - `2 <br /> !' <br /> Septic or Holding Tank 7,$-p 7,fD <br /> Dosing Chamber S.0 0 ✓BOO <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 MR'MPRS Number Business Phone Number <br /> /2i /c f//o le/ti _r /( JOS S / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> dk-776,VW E6s7Yr/ 85`8 3 <br /> NTll.Countv/De artment Use Only <br /> Approved 0 Disapproved Permit Fee Date Issue'dl Issuin gent Signature <br /> ❑ Owner Given Reason for Denial '3�5`0b <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />