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Safety and Buildings Division City r <br /> 201 W-Washington Ave.,P-O.BOX 7162 Sanitary Permit Number(w be filled in by Co.) <br /> Madison,WI 53707 7162 l I <br /> •::,�r.fir;=�=: '� � l `tY i� ��I--1�S-� �"` <br /> l state Trausac'on\'umber t Pelmit <br /> fn accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms farstate-owned POWTS are submitted to Project Address(if different than trailing address) <br /> the Deparment of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> urposes in accordance with the Privacy Law,s.15.04(01m).Slats. <br /> i. APPUCation,information—Please print Al 9ormatiou <br /> Property Owner's N Parcel <br /> . <br /> a7•o2o Z-+ -�b- -cvu �Zc�do <br /> ProperyOwncr's $ailingaddress �j1'f D1 /' PropemrLoca�ion <br /> Z �Z �� /!fit TC/W1 �`� Govt.lot <br /> Gity,State� PItonelsumber =!, V., Section <br /> r �! • tG [�lLZ y�� �• R �6,ctrcie one) <br /> T <br /> M ;ype tit Building(check all that apply) L at_ ' ry T--�' s=—$or W <br /> 1 or 2 Family Dwelline—dumber of Bedrooms Subdivision Name <br /> n - Biocl;= <br /> jPubliclCommerciai—Describe Use /r/V I» - <br /> G City or <br /> ❑State Owned—Describe Use CSM Number ❑Village of R Totvn of�yt�Lae-1 <br /> i <br /> I L T};ne of?crmit: (Check only one bps on Itne A. Complete lope B if anpl.cablee) <br /> A. <br /> 19 c lekv System Replacement System ( ❑T=catmen_l Bolding Ten. Replacement Only Other Modification to E.listing System(explain) <br /> 11 jtt! <br /> a• ❑Permit Renen al ❑Permit Revision ❑Change of?lumber ❑Permit Transfer ro\ew List Previous PerntitNumber and Datelssued <br /> Before Mx.imLion Owner <br /> 117.Type of I?QWTS SystemiCotnpottentiDevices (Check all that apply) <br /> V111on-Pressurized In-Ground 01 Pressurized in-Ground 0A,-Gmda ❑tMound>24 in.ofsuirabiesoil ❑Mound<24 in.ofsuitablesoil <br /> ❑Hpldin�Tani; ❑Other Dispersal Component(explain) Q Prerapnent Device(explain) <br /> V.DispersailTreatment Area Ta ormation: <br /> Dcsi_n Plow(_pd) Design Soil Application Raic(e,,,pdsf) Dispersal Area Acquired(si? Dispersal Arca Proposed(sf) System Etcti�a�o t <br /> 1- �- Zo71 Zo?[ I q2.7 <br /> V.Tank_nfo capacity m Total i =of Manufacturer <br /> Gallons Gallons Units '- <br /> 3 <br /> NewTznls EctttingT.mLc } o C3 '_ a, <br /> y` t� to <br /> Septic or Holding Tank 7 T" + !m I <br /> Dosing Chamber ! J 7 K7v y <br /> VH.Responsibility Statement 3,the undersigned,assume responsibility forinstallarion of the PO'VVTS shown an the attached plans. <br /> Ptum}�eris iia�Print} r Plumber' ttue hll'/MPItS Humber Business phone <br /> Number <br /> !�cA� <br /> Plumber's Address(Stn:et.City,Slat%Lip Code <br /> Vtaa.Couaty/Department Use Only <br /> AApproved ❑Disapproved Permit Fee Date Issued ing Ase t Signature <br /> l O Owner Given Reason for Denial <br /> I .Conditions of ApprovallReasons for 3isaparoval <br /> Attach to complete plans for the system and ittotheCounilraiy-Ink per not hss than 3 it s 11 Inches in size <br /> %hlj0ec.f2.G�. <br /> SBD-6393(R.111I I) N <br />