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� a�caaTxlgyro County <br /> Safety and Buildings Division <br /> a 4 q 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> ��toNa15588 '7 <br /> Sanitary Permit Application State Tr action Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governments]unit iLuwti) <br /> is required prior to obtaining a sanitary permit. Note:Application forms 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 1 m,Slats. ;?472,3 [SOS M O p <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# o <br /> ,Q/'41 e__ © /`ten wletl 3 -s o 6- <br /> Property Owner's Mailing Address / Property Location c_ O nl <br /> y 717J S /jAssli/oe d r, <br /> Govt.Lot <br /> City,State 7 Zip Code Phone Number <br /> 1/ 5 /P� �i' S�99J� _ '/t, Section J <br /> t Gs/as,� 3(,�3 circle one <br /> T a g N; R=.'jE ob <br /> II.Type of Building(check all that apply) Lot# <br /> )&I-or2Family Dwelling-Number ofBedrooms 2 L Subdivision Name <br /> _ Block# — <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> VOL s P 79 2�Townof_4ArOLLr-rrrE - <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. P-NNew System ❑ Replacement System y p ys ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑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 System/Component/Device: Check all that apply) <br /> O'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3O ° / 7 v� 9 411-5-0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E <br /> New Tanks Existing Tanks o v y <br /> a U o0 <br /> Septic or Holding-Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print / Plumber's Signature MP/MPRS Number Business Phone Number <br /> e 7�C <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1:3o.X S-141 <br /> VIM.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Signature <br /> $ I C/ut 2-1 <br /> ❑Owner Given Reason for Denial 360 <br /> LY.Conditions of Approval/Reasons for Disapproval <br /> M-16 ; panel c atm 4,W610a,, A pa"/ if, Gov.z4 r3 + LoT / CSS //u/. ?9 71 1/Sa r 6n�• Co>3. /y <br /> Attach to complete plans for the system vnd submit to the County ovly on paper not less than 8 In x 11 inches in size ` w <br /> SBD-6398(R. 11/l1) <br />