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• <br /> County• <br /> i~•: p _ Safety and Buildings Division Dane <—_)1\-A <br /> �`$P 201 W.Washington Ave., P.O.Box 7182 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707 7162 <br /> `� :: !3-261 _ bOD P7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 Depamnent 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)-Stets. RECEIVED <br /> L Application Information—Please Print All Information C U KA`t L A r•i E.- <br /> � <br /> Property Owner's Name Parcel# <br /> l-4-12.L A W.1) T1-1-S ESA D V 0 R A I` FEB 0 5 2016 v 0(4 0'7 - C U- 9 o > (-Z <br /> vPmperty Owner's Mailing Address <br /> Property Location <br /> 210 CGS.►spy Vi E.to R(3A I) Public Health MOC <br /> Govt.Lot <br /> City,State Er'vlronmental Health <br /> Zip Code Phone Number <br /> Ve-R.0 Ni A k./ 1 ,,-- 3 591 v S w %> N %., Section I <br /> IL Type of Building(check all that apply) : Lot# T Co N; R '7 E <br /> 1 or2 Family Dwelling—Number of Bedroom 4 / C Subdivision Name <br /> Block# <br /> ❑Public/Commerci.i—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of • <br /> ',z, ©E5s9(.4, ®Town of SPRANI.(rip ACE= <br /> ID.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 1New System ❑Replacement System <br /> ❑TreatmrnVHolding Tank Replacement Only DOther Modification to Existing System(explain) <br /> B. C3 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Perm it Transfer to Nov List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all th ■ <br /> El Non-Pressurized In-Ground QPressurized to-Ground QAt Gr$d%��%ound>24 in..o^of"_suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank lather Dispersal Component(explain) [_[Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> CEO 0 . 6 / c c.�a. <br /> VI.Tank Info Capacity / S er i A T S i Tim <br /> tY� Total #of MttrtufaMUrer <br /> Gallons Gallons Units = t z <br /> New Tanks Existing Tanks c U = —° <br /> s CJ y 2 m ii a <br /> Septic or Holding Tank 1��!_ - IX <br /> —V = <br /> Dosing CMmber �5 G - _i�i(u .�- ILL E.A o E 1 I <br /> U50 i Mir II.Responsibility Statement-i,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Busincss Phone Numbcr <br /> /i^i'OtzFW 'LtI iitc nry r-rC.L,Z <br /> ✓T' t`V Z2-O 11:e 608-831-8103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6813 County Highway K,Waunakee WI 53597 J <br /> �_.e---- am__ W' 1 <br /> VIII.Count�epartment Use Only / r, <br /> ved ❑Disapproved Permit Fee ' Date I ed Issu'� _ent Si �`� °� <br /> ❑Owner Given Reason for Denial S I Ip �/ .� <br /> 1 ^ i t <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not lets than 8 Us x 11 inches in size — <br /> SBD-6398(R,11/11) <br />