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ZI s Safety and Bwldmgs.Division <br /> p 1400E Washington Ave Sanitary Permit Number(robe filled in by Co.) <br /> I " Sp. P.O. Box 7162 _ <br /> -Sy Madison,Wl 53707-7162 5 �6�� _ <br /> .Sanitary Permit Application Stam Transamion Number <br /> In accordance with SPS 383.21(2),Wis,Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POW'I S a or samiucd to Project Address(if di foatrt than mailing address) <br /> the Department of Saltily and Professional Services. Personal information you provide may be used for secondary � j�3ytLa/y D <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> 1. Application information-Please Print All Information - <br /> Propert Owner's NQ�ne Parcel is <br /> rr�CA � +�S d ,O-1-aZ9'2-4o/HOS-S rY,-oerf-DISgoO <br /> Property Owner's Mailing Address Properly Location <br /> S670 Gnvt.lul_ _ <br /> City.Son, �/ " � Zi`p code <br /> �� / Phhone Numhcr y, 5, Section <br /> in dI3 /v. Ssla� b/ —SSy- 77c?9 .r_ N: R circlC mnV <br /> 11.Type of Building(check all that apply) Lot k <br /> At or 2 Family Dwelling-Number of Bedrooms _ Subdivision Name <br /> Block 4 <br /> U 1'ublidCmmmcrcial-D.6be Usc ❑City of <br /> CSM Number U Village of <br /> U State Owned-Describe Use .�-9'ow <br /> V/ of <br /> �/ of0 <br /> III.Type of Permit (Check only one box online A. Complete line B if applicable) <br /> A' ❑New System KReplaccricat System ❑Trcetment/Holding I aids Replacement Only U Odra Modifcmimn to Existing System(explain) <br /> B. UPermit Renewal U Permit Revision U Chengc of Plumber ❑Pertnil l'ranslcrm New list Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV,T eorPOW'rSS 5terNComanent/Device: Check all thorn 1 <br /> Non-Pmssuriecd In-Ground UPrcssurired in-Ground ❑At-Grade UMound>24 in.efsuitablesoil U Moand<24 in,ofsultable soil <br /> ❑Holding Tank U Other Dispersal Compmmnt(explain)_ ❑Pretreatment Device(explain) <br /> V.D1s erva/Treatmout Arca lnformntioa: <br /> Design Flow(gpd) Design Soil Application Rmag,olDixpersai Arca Requircd(s0 Dispersel I aProposed(i System Elevation <br /> 300 a17 yso �Y <br /> VI.Tank Info Capacity in Taal q oI Mauritania <br /> Gallons Gallons Cars u _ <br /> New T-k, Ee+9iag'taa4a <br /> U <br /> Soaker Rcaak kA 75-0 7,50 G�L _ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,vasmnc k,n...nlLOlry our i.mllarina ao the POINTS shown on[be xhaHvd plans. <br /> Plumber's Name If lot) Plamar's Signe:cle ///l MP/MI'RS Number Business Phone Number <br /> WADE RUFSHOI.M / a J 227691 715-349-7286 <br /> i <br /> Plumbes Address(Street,City,State,Zip Code) C/C/ C�F'" <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.Count /De artment Use Only <br /> Pcmrit Pec Uatc issued [oan,Agent to , <br /> Approved ❑ DisapprovcJ <br /> U Owner Givon Reseal for Denial <br /> IX.Conditions of App1,e,-ERcmums for Disapproval <br /> �•: I�1 v IIIU,I� <br /> �l 'JUN 24'2014 <br /> x it v- <br /> m rumnlete pl.m tar tar system and submitmm•caamy aalympmer oat tors doe BURN ETT COUNTY <br /> -- .-__ ._---' ZONING <br />