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<br /> tF\ �� _......I I! County.' '
<br /> i;Ffl �'.,;t ) Safety and Buildings Division 0.yi..2.
<br /> (WI 0 { 201 V'1/Washington Ave.,P.O.Box 7162
<br /> i $ I'l I i JAN 2 1 I •,,t g Sanitary Permit Number(to be filled in by Co.)
<br /> V\'`� P g I� ,I Madison,WI 53707-7162
<br /> ��•,,, t; f' i- 1 /3-aai�r boo>�
<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 dif erent 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 Xm),Stats. (,t`Ca f?ci(J I C W C;/G/t;
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name Parcel ii
<br /> Randy PC-fei� (NjLo Ow.W) ArThatrew L). 1,4e;n i1.4)12.- C/J//- 3r;/- /3//- o
<br /> Property rn(ner's Mailing Address C fv •A-/e.ir /4f- ,�/e.. ...c�fc.
<br /> •-� Property Location
<br /> 6 8I G/ N /f//' Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> N4 'A,N� %,, Section 30
<br /> t!Ncw4.00,-16-g.c. Gtr. , .53 c17 T 9 N; R /i E
<br /> II.Type of Building(check all that apply) Lot ii
<br /> �/
<br /> 9.1 or 2 Family 0%r -Number of Bedrooms / 1/ Subdivision Name nn
<br /> Block! &ranUv.e(.v /a,Yk
<br /> ❑Public/Commercial-Describe Use
<br /> ❑City of
<br /> ❑State Owned-Describe Use CSM Number ❑Village of
<br /> JTownof .3(;3/1
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) -
<br /> A. New System ❑Replacement Sy stem
<br /> ❑TrealmenUHalding Tank Replacement Only ❑Other Modification to Existing System(explain)
<br /> • ❑Perm it Renewal ❑Permit Revision �-yy List Previous Permit Number and Date Issued
<br /> B
<br /> ❑Change of Plumber OPemiit Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> ) on-Pressurized In-Ground ❑Pressurized In-Ground QAt-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
<br /> ❑Holding Tank ['Other Dispersal Component(explain) OPretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation r
<br /> 600 }"' » . 4-7 /S sn-- /Y/2_ .5":46; 9.417 (.9 y/
<br /> VI.Tank Info Capacity in Total N of Manufacturer /
<br /> Gallons Gallons Units t G
<br /> S
<br /> New Tanks Existing Tanks u U B B L' '• is 0
<br /> U
<br /> U v, rn wU' Pr
<br /> Septic or Holding Tank /a O C) 70V / / .--0-4-
<br /> Dosing Chamber 0 p U 4,if,Co /
<br /> VII.Responsibility Statement- 1,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 /> AO/6W W. /4e•)-l/ /2 ,..f1-s-2 4 ,,,-.1-0/65 66,9-,931- 9(0 3
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 6 B/ C if "/C' A)a..-_,,,./c.,, ct), , S sr/
<br /> 7
<br /> VIII.County/Department Use Only
<br /> ,Approved ❑Disapproved
<br /> Permit Fee Date Issued Issuing A: _•cure
<br /> / ❑Owner Given Reason for Denial 8/13/• — /)
<br /> M.Conditions of Approval/Reasons for Disapproval //
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IN s I1 inches in size
<br /> dilu - (,51 ) `f
<br /> SBD-6398(R. 11/11)
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