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Cotmtyr�l.'.,4. <br /> I(:-..,k • � Safety and Buildings Division ' (".',3'^<<`i.e.XXI 201 W.Waehington Ave.,P.O.Rox 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 �02� <br /> ki <br /> ,? J 3-2 5— 3 <br /> ' Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),WIe.Ador.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for stato•owned POWTS are submitted to Project Address(If different than mailing address) <br /> the Department of Safety end Professional Servles. Personal inibnttation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stets. r t r l `1� \ I . .. s&) <br /> I, Application Information-PleasePrintAllInformation b�� Jl(dJ� <br /> Pro Owner's Name + ei � O`�!/& -I eti y 61L3)-6 <br /> 0406- aMd She/I ly 6) 6e, eA/t_ <br /> f�perty Owner's Melding Addr /, y� Property Local it <br /> _!_I�� Lfi /�C; V cal `1 LA) • Gout,Lot <br /> City State l !! Zip Cods ^ Phone Number <br /> l e�i� ', /r,Section <br /> ��ew 4Qf2c i �SS7 �� _�1� ' D3 1 T _14 R (otrclBor V <br /> IL Type of Building(cheek all that apply) Lot if <br /> �7 Subdivision Name <br /> 1 or 2 Pettily Dwelling-Number of Bedrooms, OC //a( /��i r, r r <br /> Block✓! ��r i(�i`Cg•C , <br /> ❑PubticIComrnerelal-Describe Use ❑City of <br /> . CSM Number ❑Village of <br /> ❑State Owned--Describe Uso C1 gut.(2)-(3 <br /> ormof 1\ `,, <br /> -III.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A' ❑New System 0 Replacement System ❑Trcalnmcn t/Holding Tank Replacement Only ikOtherh edification to Existing Systo (explain) <br /> 1111 i <br /> G <br /> List Provi•us Permit Num• r and Datc Issued <br /> ib ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Penh it Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POINTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In.Ground ❑Pressurized frGround ❑At-Grade ❑Mound?24 in.of suitable soil Q Mound<7A in.of suitable soil <br /> o Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> — <br /> V.Dispersalll'reatment Area information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(of) Dispersal Area Proposed(sf) System Litevation <br /> VI.Tank Info Capaetly in Total Nof Manufacturer <br /> Gallons Caliete Units Eti �r kr <br /> Now Tanks HsistingTsei:s 1 :J rU <br /> ?n yr w C7 <br /> Septic or Holding Tent; • <br /> Dosing Chamber <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for instrtllallon of the POINTS shown on the attached plans. <br /> Phut ber's Name(Print) Plumber's 3igna re MP/MPRS Number Business Phone Number <br /> �'l i �-kN1 tf �t ` 'pct �ti1 tL e 44 I (a .0,: ajrf <br /> Plumber's Address(Street,City,State, 'r Co ) <br /> O. . r ` i.c► Ct; 01,, 5v-3S 2 <br /> VIII.County/Depnrtmenj se Only <br /> A roved ❑Disapproved Pc i!Fec Date Issued / issuing "��nl�SSiignaattuy�re. i"'_ - <br /> PP ❑Owner Given Reason for Denial S 7/— i—r7~`5 _ '� / " ' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach tocomplera Moos forthanlalemandtubmimIntheCounty onlyonpapernotless!ban8InxiIinchestosire <br /> SIID-6398(R.11/11) ' <br />