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•i' -^+ ,,,s, County
<br /> r' ? q,._ Safety and Buildings Division w'
<br /> w t tl 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co,)
<br /> e,.
<br /> �,� Madison,WI 53707-7162
<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 Service. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats, P'721 /A-..? C/PUE
<br /> I. Application Information-Please Print All Information I I t71��!
<br /> Property Owner's Name Parcel#
<br /> < t gg 6lr ,. J'q ( 07i(_ on - €(8 0 _0
<br /> Property Owner's Met aailing Address Property Location
<br /> rt/ g- R I)/ L
<br /> Govt.Lot
<br /> City,State Zip Code Phone Number n(rC ,� K`./ , V .
<br /> /,, Section
<br /> VW .DYNE/ /^W� c�q 7 q (circle one)
<br /> II.Typo of Building(check all that apply) l ( Lot# T r7 ,N; lZ ( S errhi-
<br /> ( Lor2FamilyDwelling-NumberofBedrooms Subdivision Name
<br /> Block#
<br /> ❑Public/Commercial-Describe Use ❑City of
<br /> ❑State Owned-Describe Use CSM Number El Village of
<br /> 6 771/4( ) ,Town of C° GZr'i
<br /> III.Type of Permit, (Cheek only one box on line A. Complete line B if applicable)
<br /> A. R 1r(t.-7'r/ .
<br /> ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only PV•94.thau.a.e.diaaalion to Existing System(explain)
<br /> B. ❑Permit Renewal ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> Before Expiration Owner )4'E Q7OI9/ t ...lO-47. •
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply) . 'TAN,''TAN,' f.06Pb 7
<br /> } .Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in,of suitabl soli
<br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Informations
<br /> Deal r Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sf) Di rsal Area Proposed(s1) System Elevation
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks
<br /> SeptloorliektitrgTank 1000 (Oa, ( f 74 4e k'pf '' .
<br /> Dosing Chamber «I c /r L�
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation(lithe POWTS shown on the attached plans,
<br /> •Plumbe , Name(Pri t)' Hunter' tgnature l 7 MP/MPRS Number Business Phone Number
<br /> i- et--0►. ire il/eeL i x.441 /L`ii./,- 65-9,5-53 26'z-.68 -ec17e;',)
<br /> Pl ber s Ad ess(St e,City,State,Zip Code) i
<br /> Kee/ed .//4. i'n ' I f >?2O � ' 4 l 7-Ace- s4,, i 5--� zy l
<br /> cl�►�i � I� � .�c��t'- D �.0
<br /> VIII.Count>/Department Use Oiy
<br /> 4pproved ❑Disapproved
<br /> Permit Fee v� to Issued Issu' Abe ign
<br /> ❑Owner Given Reason for Denial GL..�� i/8-27/s
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> 4P2L) > ?.e OP E— - '4C c 77077 7� -' s'(7iin,
<br /> f6 7 --- ,r- , - 7 2r\. Rte"a,o /..-1;. E ow f/r4 6-Pc T4"(- F 4
<br /> Attach to complete plans for the system and submit to the County only on paper not lees than 8 1/1 x 11 Inches In size
<br /> SBD-6398(R.11/11)
<br /> C( rt Or 'rl 4O(,,44 C4/ �•
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