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-T,.. <br /> rf: = County <br /> Safely and Buildings Division <br /> ® `C� <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison Wi 53707-7162 <br /> Sanitary Permit Application V � State Transaetion Nttmbcr <br /> fn accordance with SPS 383 21(2),1Vis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pertnit. Note:Application fortes forstate-owned POWTS are submitted to Project Address(ifdiffrrent 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 Lair,s.I5.0411)1m),Stats. <br /> L Application information—Please print AR Information <br /> Property Owner's N �J { Parcel <br /> //� `�Jal��Z��n1� 07•p20 Z^�Rl�lb- •j/ -o�w� 1Zapc <br /> Property Owner's\faiiin_Addresss Property Location <br /> lc A?d/2j5— Govt Lot <br /> City,State Zip Code PhoueNumber Z <br /> Section <br /> Q[� <br /> �+� {� • J L�v ` 3 �- �'�62 circle one) <br /> T�N1; R Ord;or'V, <br /> Is.Type of Building(check all that apply) Lot <br /> ❑1 or?Family Dwelling-dumber of Bedrooms Subdivision Name <br /> Block= <br /> TPub[ic/Commeriaf-Describe Use /r/V to ❑city of <br /> ❑State Owned-Describe Use CS,%-I Number ❑Village of <br /> 5tTotvnoF--64t •+� <br /> II .Type of?ermit: (Check only one box on line A. Complete Tine B if applicable) <br /> A. I <br /> 4 New System C1 Replacement System ❑T,.-annentttHolding Tan',Replacement Only ❑Other iviodification to Existing System texplain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber I List Previous Permit Number and Date Issued <br /> g If ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV-Type of POWTS System/Celm onentlDevtce: (Check all that apply) <br /> VN.n-Pressurizedln-Ground [I Pressurized In-Ground ❑At-Grade Q Mound>24 in.ofsuitablesoil ❑Mound<24 in.ofsuitable soil <br /> 0 Holding Tart; ❑Other Dispersal Component(ex-plain) ❑Pretreatment Device(explain) <br /> V.Dispersair-Freatment Area information: <br /> Desien Plow(gpd) Design Soil Application Ratcfgpdsf) Dispersal Area Required(sl) Dispersal Area Proposed fsl� System Elevation <br /> 1- Z07/ 7-071 2 <br /> V:,Tanis info Capacity in Total r of Manufacturer <br /> Gallons Gallons UnitsIU <br /> c <br /> New Tama <br /> septic or Holding Tank 1 (rC 1 ( �y • f <br /> Dosing Chamber ly <br /> U 1.Responsibility Statement-L the undersigned,assume responsibility for installation of the PONVTS shout on the attached plans. <br /> Plumber s Namc(Pant) Plumb Signature RPfMPRS Number Business Phone umber <br /> Plumber's Address(Street City,State,Zip Cod-) f �� <br /> �G�C� �gl/•!�r'�'S.���[,! <br /> V111.county/Department Use Only <br /> proved ❑Disapproved Permit Fes Date Issued is wing A� Si, ature <br /> ❑Owner Given Reason for Denial S -s <br /> I z.^Conditions of ApprovaURensons for Wisopprovttl <br /> Attach to complete plans for the system and submi r on paper not Iess than S to x 11 Inches in*e <br /> SBD-6398(IL 11111) <br />