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✓ County <br /> � t` Safety and Buildings Division h 0-- Jn <br /> ��r q , : i gj 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> e) - ' I r Madison,WI 53707-7162 <br /> �-;. � 13 - 2b1 7 DoS� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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 Law,s.1s. Personal information y�pr4yjtje y for secondary a <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stars. KK E((,„�_,, E Q m e t R <br /> I. Application Information—Please Print All Information a... I q <br /> Property Owner's Name Parcel# <br /> NDker i1 i abyn . I/%I FEB I71015 data - 3 ,?a - `2/1> > -e <br /> Property Owner's Mailing Address Public Health t C Property Location <br /> 5 (& 5 L eX i n i )-a & b r- Environmental Health Govt Lot . <br /> City,State y Zip Code Phone Number .S (4)/, 4.1 y. <br /> 14' , Section 3 a <br /> O r e, O f4 f-l!z (circ ) <br /> II.Type of Building(check all that apply) Lot# T N; R /t9 ! <br /> ❑1 or 2 Family Dwelling—Number of Bedrooms 1 Subdivision Name <br /> /Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 9 3 $$3 `g o w n of rvk llf I.A $ <br /> III.Type of Permit: (Checkc 'e-Boro iqe A. Complete line B if applicable) <br /> J <br /> A. .hlaw,Syetens - Replacement System 31 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ,,J <br /> B. ❑Permit Renews`--.-0 Pertnit REv ion- ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 4 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ii'on-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 a Required(st) Drspe 1 Area Proposed(sf) System Elevation <br /> 4z>p r.7d tti /.s-6C )..51a- `til. 0 q4,6� le,6i <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o$ <br /> New Tmtks Existing Tanks , 1 .> t <br /> n. 1 4 0 in CA tr u e. <br /> ,. Septic or Holding Tank t /2 8 /.8 4 / ' /�/J�y d <br /> Dosing Chamber / <br /> VII.Responsibility Statement-I,the undersigned,assuur , ...,sibility for nstllation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum..- Sign:I vI /MPRS Number Business Phone Number <br /> Sfiel/ Cr-osb� c�.__ __ aaaali $ 9 9- x77/ <br /> Plumber's Address(Street,City,State,Zip Code) (- <br /> 73 ko / D Ir )rL 'Ds- 40 4ri-s, L 535„II <br /> VIII.County/Department Use Only 'i <br /> pproved ❑Disapproved Permit Fee Date Issued Issuing gen ;$ <br /> ❑Owner Given Reason for Denial T” A 0, 5 : <br />