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",x _sia,;r. County <br /> i;: ? '\\ Safety and Buildings Division Dane <br /> ,i5:-:-// <br /> _ , D 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> (y1 SP 1~1 Madison,WI 53707-7162 <br /> s �zi <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),Stats. f,5 i (2 I ltA I L- <br /> I. Application Information-Please Print All Information 1�- <br /> Property Owner's <br /> c' Name (c/o M A,f`rC Parcel# <br /> V)AuLt\AI u l V e:to .rvl Et <br /> Bt4I u)l 4 C c <br /> D ESQ 4j a <br /> , I - <br /> I Z 1- G 14 - -c <br /> Property Owner's Mailing Address P y Location <br /> P o ox (.4 <br /> Govt.Lot `` n <br /> City,State Zip Code Phone Number ' /e, N I '/4, Section t o� <br /> N � <br /> Sufi PIZA I IZI U 11■ , ``ICJ <br /> II.Type of Building(check all that apply) ` Lot# T ! N; R E <br /> sii or 2 Family Dwelling-Number of Bedroom. `d Subdivision Name <br /> Block# 0 t2u,(��..(fiq �lL�-e: <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> &Town of Biz t S1 c2 L. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 12New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Chan a of Plumber List Previous Permit Number and Date Issued <br /> Change ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> SNon-Pressurized In-Ground Pressurized In-Ground at-Grade OMound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ❑Holding Tank ['Other Dispersal Component(explain) Dretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 0200 e /j1/4S-00 / DA 9'1.2 'n. " . <br /> 91 5- 97 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .n o'd ` 2o <br /> New Tanks Existing Tanks ° c . s 1 s g c5 i n &) u. <br /> t P. <br /> Septic q.Ba2diog Tank f `% <br />