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.:aL��.xz'r.?TJX <br />_. <br />County <br />' <br />Safety and Buildings Division <br />urxe4' <br />201 W. Washington Ave., P.O. BOX 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />Sanitary Permit application <br />StatcTransaction Number <br />In accordance with SPS 383.21(2), Nis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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. <br />-711. 4 ,; <br />A tication Information — Please Print kit Information <br />Property Owner's Name <br />Parcel <br />,/1q7 Tei <br />7-0 0 1-Y0-16-3/-oS-0Oh'-az3CDC <br />Property Owner's Mailing address <br />Property Location <br />l 7ON A� <br />Govt. Lot i <br />y, 'h, Section,{ 1 <br />City �tte <br />Lipi-Odle Phone <br />Number <br />/ 1► /'�rGK%( / r/� <br />/� <br />'70 N: R /�circlEoonc`�'1 <br />Il. Type of Building (check all that apply) Lot <br />i_ <br />Subdivision Name <br />I or 2 Family Dwelling —Number of Bedrooms <br />Block <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />CSNI <br />❑State Owned —Describe Use <br />❑ Village of <br />Town of 0(l k—k; <br />Number <br />11I. Type of Permit: (Check only one box on line A. Complete Iine B if applicable) <br />A. <br />❑ New System <br />'Replacement System <br />❑ Treatment/Holding Tattle Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />11 Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owneri✓/ti' <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 Taiu; ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Plow (gpd) <br />Design Soil Application Rate(epdsf) <br />Dispersal Area Required (sf) <br />Dispersal Arca Proposed (sf) <br />System Elevation <br />If50 <br />V'. Tank info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />� <br />Gallons <br />Gallons <br />Units <br />U <br />New Tanks Existing Tanksu <br />a o C 0r2a r <br />L C L n C/J 0 a. <br />Septic or Holding Tank <br />O OL I <br />M�,` <br />�Z� <br />2 <br />5 W <br />Y` <br />Closing Chamber <br />VII. Responsibility Statement -1, the undersigned, assume responsibility for installation of the 1`0*�4"TS shown on the attached plans. <br />Plum s Name (Print) <br />Plumb ' S' nature <br />MPJNPRS Number <br />Business Phone Number <br />s <br />lis- SM -0- o Z -- <br />Plumber's <br />Plumber's Address (Street, City, State, Gip Codes-) <br />VIII. County/Department Use Only <br />approved <br />C1 Disapproved <br />Permit Fee <br />Date Issued <br />Issui Ag t atu <br />❑ Owner Given Reason for Denial <br />S <br />I L. Conditions of Approval/Reasons for Disapproval <br />l0 �� A orabovt 93ppS��ac <br />yeZ1ov Zk' = 933.°° 1,4Nk �Pn/I" w /Aiv�S �jU�strs <br />Eu"E E <br />V <br />FD) <br />Allach to complete plans for the system and submit to the County only on paper not less titan a ur z i { Tcn7[n 'TRAY 1 4 2018 ' t' <br />tt_i U <br />SBD -6398 (R, 11/11) &kJ t,.T**TT COUNTY <br />ZUiNIPtJ%i <br />