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-e iii; County <br /> Safety and Buildings Division a N H C <br /> Iti <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> :¢ ` DAP I,I Madison,WI 53707-7162 <br /> t `':a. rf <br /> r <br /> \• 13-tots- ao l93 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Aden 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 info .Ei..i Y eE rrcondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. C V C .J 1 5 3 a W ti•\-k-e.-c- 4iffi <br /> L Application Information-Please Print All Information <br /> Property Owner's Name JUN 12 2015 Parcel# <br /> R ;C_h o c--a r 0.\m e salt realm � 0 5 0 2 1 <br /> Property Owner's Mailing Address Property Location <br /> °, L` aYl 0.N 0. G N Dr, Environmental Health <br /> Govt Lot <br /> City,State Zip Code a S <br /> I -9 Phone Number �� +� S�,�,) �/, Section <br /> \l Ero;V a , W.1— j q 3 irca ) <br /> II.Type of Building(check all that apply) Lot# T N; R oneW <br /> .�1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# 3S rx:ce perce <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> g)Town of (-no/Q-A-N-05 L'. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System Replacement System ❑Treatinent/Holding 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 /> N.Type of POWTS System/Component/Device: (Check all that apply) <br /> . S.Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Piet eatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil A plication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) S stem Elevati n - <br /> �t5o r/a 5 1 to € _ 'y�o 9seiz/ <br /> .:VL Tank Info Capacity in Total #of Manufacturer <br /> g <br /> Gallons Gallons Units o $ v <br /> Near Tanta Existing Tanks 82 c d .E y P. is <br /> c.U ti . vi 0.CD R4 <br /> Septic or Holding Tank tobO Io .C, , D`milQ. ` x <br /> Dosing Chamber I <br /> VII.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 Business Phone Number <br /> --FpACA- c 3J\-e- (\i ei 1 - 4 15 5 6'O8 15 7/G( <br /> Plumber's Address'(Street,City,State,Zip Code) c u a <br /> I 330 Vr t- R c t . /f '& . W_l - f---_._..._..dq. <br /> VIII.County/Department Use Only -? \ <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing gay - /J <br /> Y.01 ''o-f5f <br /> ❑Owner Given Reason for Denial . <br /> IX.Conditions of A proval/Reasons for Disappro .1 <br /> CL6if, �/ <br /> - , ,•/ a-5 zeD-e,,._ ced,_ , <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 a 11 inches in size <br /> SBD-6398(R.11/11) <br />