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._:_:_.., County 1� <br /> .&. Safety and Buildings Division Dane <br /> _�• 201 W_Washington Ave_,P.O.Box 7162 Sanitary PamitNianber(to be filled in by Co.) <br /> 1 S a _ Madison,WI 53707 7162 <br /> -, (3 -2di (I-6a ((017 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wit.Aden Code,submission of this from to the appropriate governmental unit <br /> is required prior to obtaining asanitary permit.Noce AppEcalim forms for state-owned POWTS are submitted to RojectAddres(if rEfferent than malTng address) <br /> the Department of Safety and Professional Servies_Personal information you provide may be used for secondary (/�,�// /�" +n` <br /> purposes in accordance with the Privacy Law,s.15.)4(1)(m),Stns. V 12, 0 Kt r-t e ,\o MD <br /> L Application Information—Please Print All information <br /> Property Owner's Name Parcel 4 <br /> JOEL- /21.14D LtS/-CL. Q o&oS-351- 9711 - 0 <br /> Property Owner's Mailing Address Property Location <br /> 524t FRtsco Cou2T Govt Lot <br /> City,,�S�/qm I tt Zip Code Phone Number SE ry,(4,E '/t Section J 5 <br /> IJ/ItOt)L.E-m." lul 535&Z. T $ N; R S E <br /> IL Type of Building(cheek all that apply) 1 Lot 4 <br /> gi Of Family Dwdlirrg—Number of 5 2 Subdvisign Name <br /> Block. <br /> QPubbdCm®ccial—Describe Use 0 ay of <br /> CSM Number ❑Vllageof <br /> Qstaa Owned—t)rseribeUse (0542 NTownof SPR.LMAc1E.L-O <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. I(New System ❑Replacement system 0Treamternifiolefing TankkRReplacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision []Change of Plumber []Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of FOWL'S System/ComponentiDeviec (Check all that apply)" <br /> e1 Non.Piemai�tIn-lGround DPremuized.In-Ground l}it-Grade Mound>24 in_of suitable soil []Mound<24 in_of suitable soil <br /> ❑Holding Tank 00t her Dispersal Component(explain) Qt'n.u..m....nt Device(captain) <br /> V.Dispersal/Treatment Area information,�r �1 Atha Reguire�(ssj Dispersal Area Proposed(sfl I System Elevation <br /> Design Flow(gpd)5�IJesimsolA --y ( / ,'--)5 I /550 1, .,.. �`7; 97..v./ _,. cif 9 <br /> VI.Tank Info XJ in Total M o U° — <br /> New Tanks aiming Taaks a r3 co a s O i= <br /> se andb sTadk 1(42 50 ((.5o a c > <br /> r>ash=Chamber boo P)ooI I M, woe <br /> Vn.Raspou-6clity Statement-I,due undersigned,assume responsil lity for instaliafion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 1 Plumber's Signate I NIP/MPRS Number I Business Phew Number <br /> ^ 220165 6084331-8103 <br /> Andrew W Me inhotz --4---C --- 1-A-), � <br /> Plumber's Address(Strom City,Stag Zap Code) . <br /> 6813 Courtly Highway K,Waunakee WI 53597 <br /> • <br /> -VIII Cotmtp/Deparimeat Use Only Stmmamc �:i� <br /> liCApproved ❑Disapproved Permit lFee <br /> 1 Date Isued Ten:.moo s❑Owner Given Reason foDe dal I S 7 J{ �i (fTi '/� `� / / <br /> DL Condt:ions of AppravallRessons for Disapproval <br /> AmickOe complete Plaas for the system and submit to the Carroty only on paper not{asthma II ins II incise;in she <br /> q45-0 <br /> SBD-6398(IL I1/1I) <br />