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``�r, • rF - County r� <br /> /} l ,'. Safety and Buddings Division Dane My <br /> s/� �'•I 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.)•$ !'4! Madison,WI 53707-7162 t_ ©t <br /> Sanitary Permit Application Slate Transaction Nwnlier <br /> In•.••• , with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit . <br /> is req -. ': to obtaining a sanitary permit. Note:Application fbmrs for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the •.., . of Safety and Professional Servits. Personal information you provide may be used for secondary �/ _ <br /> purposes ,• • with the Privacy Law,s.15.04(1xm),Stab. BA 4 �UICE(, ��= <br /> I. AppR • <br /> n Information-Please Print All Information <br /> Property . s Name <br /> M, : C V4 MADiso►J U-C Parcel ob-- 20- 6186-0 <br /> Property• a Mailing Address Party Location i <br /> 6#,of SO(A N Io vit.s E DIZt ve Govt.Lot <br /> City... :- Zip Code - Phone Number 3 , Su) 14 section 10 <br /> M - 155vi� w L , v, <br /> 5 3113 T ? N; R 8 E <br /> IL Type , tiding(check all that apply) Lot I <br /> igi I or2 ..ly Dwelling-Number of Bedrooms S I dV Subdivision � `IYV' <br /> Block f <br /> •DPubli •■ 'al-Descrie Use <br /> bcitrof <br /> CSM Number ❑Village of <br /> ['State• .-Describe Use 4 V 1 -�T UI <br /> NJ Town of <br /> III. I'ermtt: (Cheek only one box on line A. Complete line B if applicable) <br /> A. . System ❑Replacement System ❑Trcatment/Holding Tank Replacement Only ❑Other Modification w Existing sysam►( •m) <br /> B. List Previous Permit Number and Date Issued <br /> ❑��� Renewal ❑Permit Revision ['Change of Plumber ❑Pern»t Transfer to New <br /> ..,, . Owner <br /> IV. I' •*TS System/Component/Device: (Check ape that apply) <br /> N. . in-Ground OPressurized In-Ground QAt.Grade DMoemd>_24 in.of suitable sot ❑Mound<24 in of suitable soil <br /> O , . Dispersal Component(explain) ❑PrcUadnent Device(explain) <br /> V.Ms. • - ■ ant Area information: <br /> Design , •,.• Design Soil Application Rat(pdst) Dispersal Area Required(st) Dispersal Proposed(al) System El <br /> • 9 re AS <br /> •6r <br /> / J <br /> VI. i e Capacity <br /> in Total I of Manufacturer . <br /> Gallons Gallons Unit <br /> New7Lds F.xlain Tanks q 1 .1 I <br /> Sopb•or S <br /> ST 1 So I 650 a Ns `' <br /> Dozing 6 MI VIi. • - � 6ility Statement-to the undersigned,mum raponalbiN(y <br /> for Installation of the POWTS shown on the attached�lnaa. <br /> Plumber's 1 .(Print) Plumber's Signature I MP/MPRS Number Business Phone Number <br /> Melnholz I ,,� .(� 4_ 220165 608-831-8103 <br /> Plumber' (Street,City,State,Zip Code) <br /> 6813 2 Highway K,Waunakee WI 53597 <br /> zi <br /> 11 e'!, r rtmat Use Only _Issued�� ❑Disapproved � �1 l ���// <br /> lat --- <br /> �' ❑Owner Given Reason fbr Dodd <br /> IL Can.^r1 of Approval/tenon ler Disapproval �� D <br /> RECE <br /> . Apg08l <br /> Aapeeh M es.pkt.plus aer Se gable sad sank Os dm C•sab only us paper set•os Om$rA x 11 tic MM <br /> tai Health <br /> SBD-63' : i. 11/11) <br />