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I <br /> .fi`a�-4∎iri1 County <br /> (5- : . w Safety and Buildings Division Dane <br /> 1( $ .:y,ri 201 W.Washington Ave.,P.O.Box 7162 sanitary Permit Number(to be filled in by Co.) <br /> �, ..& fir Madison,WI 53707-7162 <br /> ,,',-'-±- f . 201(0— <br /> it-rca5> <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SI'S 383 21(2),Wis.Um.Code,submission of this fort to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fonns for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> Me Department of Safely 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).Scuts. CTH E <br /> I. Application Information-Please Print All Information `y-- I <br /> Property Owner's Name Parcel ��: <br /> Gary Karts I 'Ad__l.. K" i2 0606-323-8732-5 <br /> Property Owner's Mailing Address ��( �y, �qp� �` Property Locution f <br /> er:-$CX"92 ( L r^ J _._( ( 7 . Govt.Lot "? '/a, , � J l c <br /> City,State .. ode Phone Number NW ti SW %, Section 32 <br /> Mt. Horeb, WI 6 6 (circle one) <br /> Ii.Type of Building(check all that np ,•) Lot: T. N; R E or 1V <br /> ® I or 2 Family Dwelling-Number of Be oom I <br /> s 3 # Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use <br /> - ❑ City of . <br /> ❑StateOwned-DescribeUsc CSMNombrs ❑ Village of <br /> 8095-fit-7,' M Town of Blue Mounds <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ',' ®New System y ❑Replacement System ❑TzeatmentIl lolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before.Expiration Owner <br /> IV,Type of POWFS System/Component/Device: (Check nil that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurised In-Ground ®At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Ilo)ding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersni/Trentment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sI) Dispersal Area Proposed(sp System Elevation <br /> 450 . 0.6 750 760 98.5' & 100.0' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> u <br /> Gallons Gallons Units P o , v <br /> • <br /> New Tanks Existing Tanks c . v 2 <br /> c U iii , re i-0 F. <br /> Septic or?folding Tmtk 750/300 1050 1 Meade x <br /> Dosing Chamber 600 . 600 1 Meade x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation at the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MMP/MPRS Number Business Phone Number <br /> Ar`rorteaIJ W IDEA N 1-1(AZ �,, _- z-- ---�... a, .o I . 6 UO5 -22S-981L <br /> Plumber's Address(Street,City,State.Zip Code) t <br /> VIII.County/Department Use Only ' • ! r <br /> Permit Fee Date lssu lssui ` Anent <br /> Approved ❑ Disopproved r p 1 Q -.... ,,- _ <br /> ❑Owner Given Reason for Denial 3 1 ` ( ! ��.3 < ' /,_�f07.--- ,, irAW� � <br /> IX.Conditions of Approvnl/Rensons for Disnpprovni �" <br /> Attach in cnmptele plans for the.n'stem and submit to the County ants on paper not less titan f i to s I I Incites In size <br /> SBD-6398(R.11/11) <br />