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,� +milp-y Count <br /> Safety and Buildings Division / a rn f <br /> 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> `\ $`psi Madison,WI 53707-7162 <br /> Sanitary Permit Application Slate , sluonN mpberf�I <br /> In accordance with SPS 38311(_2).Wis.Adm.Code.submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note-Application Corms for state-owned POWTS are submitted to Project Address(ifdinerent 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 Privacv Law,s. 15.04(1 gm).Stats. 7305 Ca /7i'P C <br /> L Application Information-Please Print.All Information <br /> Property Owner's Name Parcel q p'7 O;0-4+41'0' -3' <br /> `f/etrk a- JraoP Fe�P � pl-000 -of/oo/ <br /> Property Owner's Mailing Address - Property Location PE of 61V <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> _' $((/ /., Section <br /> CAle-bsfe. W, Sa1893 gone) <br /> T //d N R /b E o� <br /> �11tt! <br /> .Type of Building(check all that apply) Lot <br /> X11 or 2 Family Dwell ing-Number of Bedrooms 3 Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use CSNI Number El Village of <br /> A Town of 04 k:/e'.e - <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System XReplacemen[System ❑ TreatmendHoldng Tank Replacement Onl} [I Other Modification to Existing System(explain) <br /> B. ❑ Permit Rene,al ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/De,ice: Check all that apply) <br /> KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inof suitable soil ❑ Mound<24 inofsuitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> vso . 7 G v3 6Z/,3 %5-- <br /> N 1. <br /> .rN7.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank )� y'-� Je(SG / tvcp <br /> Dosing Chamber <br /> VI t. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POwTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber s�Siignaturee 1MP/MPRS Number Business Phone Number <br /> � <br /> �C 1G le- /�%O lel n-f /�-mb[-o4__ re //� �r / 1 71,5^6164�— q/.$-7 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> pt 776v /Yw 3 Df/26s1-., Wr SS`873 <br /> DTII'Coun tv/De artment L se Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Ao I tare <br /> ElOwner Given Reason for Denial S 325 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D EC9E <br /> 7 <br /> N 5 2012 <br /> Attach to complete plans for the system and submit to the County only on paper not Ins Than R : 'aches in Size <br /> RNETTCOUNTY <br /> SBD-6398(R. I I/I I) ZONING <br />