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County <br /> Safety and Buildings Division V/W <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit N`�uoaiter(to be filled in by Co.) <br /> �• SPS Madison,Wl 53707-7162 I f 5 Lr <br /> °t l' Al,�-i -j 1 O <br /> Sanitary Penuit Application State TransactionNumbcr <br /> In accordance with SPS 383.21(2),Nis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fortes for state-owned POWTS 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(lxm).Stats. <br /> 1. Application Information-Please Print All Information a� <br /> Property Owner's Name Parcel d <br /> Ak u <br /> Property Owner's Mailing Address Property Location <br /> D %/ e-j a cant.Lot —�- .y <br /> City,State Zip Code Phone Number y V,, Section Z <br /> /uck w� sal -> > t�le <br /> U.Type of Building(check all that apply) Lot* ' T _N; R E <br /> �1 or 2 Family Dwelling—Number of Bedrooms /O Subdivision Name <br /> Block it T iLGfOIt- Jf Z,07 �D <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 1146 <br /> /p/D ATownof i Lk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" i�New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> E• ❑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 S stem/Com anent Tlevice: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground OM-Grade ❑Mound>_24in.ofsuitablesoil ❑Mound<24 in.of suitable soil <br /> 15 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> V t.Tank Info Capacity in Total ft of mmwiactum o <br /> Gallons Gallons Units o —o u g <br /> New Tanks Existing Tanks o a u <br /> ` c.Ci ni y in is. U —'4 <br /> Septic or Holding Tank 66 Imo./ � ldQ� Z / X <br /> Dosing Chamber <br /> Al.Responsibility Statement—L the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Pt-r ¢Jer <br /> umberZ 's tort MPiMPRS Number Business Phone Number <br /> Sig-oz.o z. <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z 7Z2o -14oi,' ln! J r -5l,F <br /> Vitl.Coun /De artmentUse Only <br /> Approved ❑Disapproved Permit—F7= Date Issued Issuing Agent Signatu <br /> P <br /> ❑Owner Given Reason for Denial S 3/�J "�� — <br /> '7 <br /> , 14 (Z� <br /> UL Conditions/of Approval/Reasons for� Disapproval <br /> is!� e &- -- oy�Jf1'4)e K 7,W e ale&, <br /> Attach incomplete plans ter the sestem and submit to the County Daly on paper not less than a 12 Ill inches in An <br /> SBD-6398(R.11/I I) <br />