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RECEI\► I y <br /> i.sximEti, t.ount <br /> � V_'. Safety and Buildings Division <br /> ! : ''• �` 201 W.Washington Ave.,P.O.Box 7162 <br /> �r::.11�;��_:; .-. JAN 0 5 Z0� 9 Sanitary Permit Number(to be filled in by Co) <br /> $ . !"I Madison,WI 53707-7162 13-20/6 /� <br /> ' y! Public Health MDC / T� , /� <br /> f.. ,,c' Environmental Health 'L/v V <br /> Sanitary.Permit Applic 1 State Transaction Nwmbcr In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this fo�epF.ill,,rL'. t - - <br /> is required prior to obtaining a sanitary permit. Note:Application forms fo t a s to Project Address t ifdiferent than mailing addresxl <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)(m),Stats. JAN 0 5 7016 72I <br /> 2L( ' 'ii kaW r` IA M-e- <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Namee('�,�, Pubfie Health MDC Parcel 8 <br /> •/-)J vii o cv► Environmental Health 452/050' -f -1 1 j' "i`U <br /> ,--the <br /> Property Owner's Mailing Address Property Location <br /> '0000 PraninZ. .S1+ €e 3 5Li1J 2-20 Govt.Lot--- <br /> Ctty.State �/�� Zi Code y� Phone Number <br /> 2 �Q �j�' SE y,. 5(,`J Section 16 <br /> qz,)t i e ( Gt w3 1 -35-7 V t7 I l- V 52-5 i O� circl and <br /> 11.Type of Building(check all that apply) Li Lot 8 <br /> Zt.I or 2 family Uwelline-Number of Bedrooms Zli Subdivision Name <br /> Block 8 °1 a t�fr/t Fula 5 <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> CSMNumber ❑ Village of <br /> 0 State Owned-Describe Use_ tiC 1 1 <br /> c.Town of tl aN(/V1./ <br /> 11 <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) --1 <br /> �/ i <br /> '' I 0 New System 0 Replacement System i ❑Treatment/Holding,Tank Replacement Only L29 Other Modification to Asting System ie\plain i <br /> , <br /> ( Mc <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> 1 V.Type of PO\%TS System/Component/Device: (Check all that apply) 1}I <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> 0 Holding'lank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: - <br /> Design Flow(epd) 1 Design Soil Application Ratc(gpdst) 1 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total t 8 of Manufacturer <br /> Gallons Gallons Units 1 . i ° 3 i _ <br /> . ^�. u u I `o s. - <br /> New Tanks ' Existing Tanks I u j I ° = e. ? _ . <br /> _ .., ii N v: I - .. <br /> Scpri o I r Holding Tank 1 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assu a res i.nsibility for installation of the POINTS shown on the attached plans. <br /> i Plu tier's Name(Prim) I Plumber'. i MP/MPRS Number Buss e.a Phone Number <br /> A-''''a-- As <br /> i <br /> Plumber's Address(Street, ity.State,Zi C.• r' I <br /> -dq' j i P 7a,.c n.. (1 t,�1 , �:L S3S c� <br /> VIII.County/Department Use Only <br /> I i Permit Fee Date Issued Issuin Signature <br /> 0 Approved I ❑Disapproved -- /J/' I� <br /> ❑Owner Given Reason for Denial I SOW? O1/671I6 !iezA `C` I <br /> X.Conditio of Ap rov ohs for Disapproval j <br /> 4 AA-4-3 ‘1,F---Ref,--Icp5Rb. 6 Ak°1-)1 Attach to complete plans for the system and submit to the County only on paper not less than 8 tre x 11 inches in size <br /> SBD-6398(R. ]ill I) <br />