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sorA5 "+> , . Industry Services Division County <br /> �� `+; 1400 E Washington Ave <br /> G f�2 <br /> $p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S /1 Madison,WI 53707 7162 <br /> 4) t� ' 3 -2bK- 00Ogg <br /> Sanitary Permit Application State TrsasactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal informatio e <br /> proposes in accordance with the Privacy Law,x.15.04(1Xm),Slats. �V 1,o 17 oy II`1,0k' LA. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name MAR 13 2015 Parcel# 6q45 7-/.83- pp 7 7,0 <br /> 1 <br /> ZL�,6 4. CNrt;t l(m/Ai. o) L.I- 17 <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> Z0/4, 4-14M bk-(n,'-e d Dr Environmental Health Govt.Lot <br /> City,State Zip Code Phone Number i 8 <br /> SAL. `� (� Q SF+ /., S� /., Section <br /> ruin:e. itt JAL LIJ� <br /> iti7 b �vD �71 - (77$ (circle one) <br /> IIe of Building(check all that apply) Lot# T N; R E or W <br /> I 1 or 2 Family Dwelling—Number of Bedrooms 17 Subdivision Name (n� <br /> NIPPY <br /> Block# l3LctLk t14tt�S Pc If) <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> E r n�`X ry <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" ) New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only A Other Modification to Existing System(explain) <br /> Re cc"��-e.L\-- <br /> List <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑N o n-P r e s s u r i z e d I n-G r o u n d ❑P r e s s u r i z e d J n-G ro u n d ❑A t .- . • ..:.>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 /> xiDesi Flow Design Soil Applicad onRate(gpds Required(s� Dispersal Area Proposed(st) System Elevation <br /> Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° °la .0 <br /> New Tanks - ing Tanks 1 q t , b 1 il <br /> Septic oNteldbrg 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 Si afore MPNumber <br /> Business_phone Number <br /> 6 <br /> .sees I�P\{.1- `i ---<e �7 C15Coa3o Go -ti3%-1 -3.75 <br /> a <br /> Plumber's Address(Street,City,State,Zip Code) <br /> y IS C��\-rLr s���\- / Sov� G: , k--1t 5-3 5 S3 - <br /> VIII.County/Department Use Only <br /> JgnPProved ❑Disapproved Permit Fee Date Issued Jssuin/, •/•i•.i� <br /> ❑Owner Given Reason for Denial $g5 74d , idw <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> PGw 2,t 6/halt- ; t ER e1 ,I?(/Y%r,e4 0/TW # 9 Elsa/. co/►. <br /> lot /7 (I J' 4 L) 8Y Ae-oup r rt.ref,-) tilt,0?-2,911._ o ciz2,17 6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 Inches In size <br /> 1401.111F1 �br�ckc�ts ,ls�CJ ��-,1- <br /> SBD-6398(R.08/14) <br />