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County • <br /> Safety and Buildings Division Dane 8m <br /> U s AUG 0 3 2016 201 W.washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P S Madison,WI 53707-7162 e <br /> Public Health MDC /3-d616 - G d d <br /> i:n"ironmental Health Stat fnsaction Number <br /> Sanitary Permit Application Transaction <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 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. FAR VI i-Ir.i F(iIi t) <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> C fk I;U 1J f S <br /> /�� T PE-i A Is.;1 E lf.J G-t3EP< L''--C)bO7- I'7:2-- 901 0 - I <br /> Property Owner's Mailing A did ress Property Location <br /> as s Kt. K A D i r.) ✓TE.E" Govt.Lot <br /> City,State Zip Code Phone Number t <br /> „...„---G‘,„1 /, j�j j� /,Section l rj <br /> SiCLACIitkZiv WI 556S9 T ?) N; R '] E <br /> II.Type of Building(check all that apply) �1 Lot# <br /> ®I -1 <br /> or Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of _ <br /> ✓9 0 5 4 YitTown of -? K y <br /> Iii.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ®New System ❑Replacement System ❑TreatmenuHnlding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground [it-Grade PC_1Mound? <br />