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. E CiElIWE "Des* (:).-3-?.6-i <br /> - ya- t <br /> • commence. _govt l(I 5 ryn�Q S a l.t tf: Buildings Division County <br /> itU V L '�`� ``jj��,r le:ton Ave.,P.O.Box 7162. D�y <br /> ' co n ♦. j M:dison WI 53707-7162 Sanitary Permit Number(to lbe filled in by Co.) <br /> Department o Co '- MI iMAID7 5/8 D 7 0, <br /> . S , a ..u. l i e ass' t o C•L ion State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit_ Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submined to Use Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Scats. <br /> • <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel N -1-, /( [ <br /> Pal i• \ i cw^ti Property i 8 3T05l <br /> Property Owner's Mailing Address pertY <br /> � <br /> 1 0 1 CO u .� Govt.Lot <br /> City,State Zip Code Phone Number 5-(a/ y,,cir,J v.. Section i i i <br /> Pi i 12..J.tr- V'j 5.393.2, a (circ one) <br /> N; R 11 cr W 1 <br /> T ` (' <br /> 11.Type of Building(check all that apply) Lot N 1 <br /> ® 4 1 or 2 Family Dwelling-Number of Bedrooms j' Subdivisio Name 1 �-n n <br /> Block# W'A t't0 GJ"' a kgt 'lt�' <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use it m Town of gfi,S/t ` <br /> III.T • . "•ermit: . eck only one box on line A. Complete line B if applicable) <br /> A " New System ❑Replacement System ❑Treatment/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 /> IV.Type of POWTS System/Component/Device: (Chet ply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized ln-Gro At-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(expl . ) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) •Design Soil Application Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> (400 a (o J�`!. 1 O o ' 'b).ti 1-- <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units o o u U <br /> ci 2 <br /> .A <br /> New Tanks Existing Tanks o o 2 Ti .' 10 `,° <br /> a U in in is_O P. <br /> gleg011tr Holding Tank I 2�-� 12.Pe <br /> om •�� � <br /> �a <br /> Dosing Chamber 90 v <br /> VII.Kesponsibility Statement-1,the un•.lersigned,assume responsibility for installation of the YVN'1.S sown on the anached plans. <br /> Plumber's Name(Pr Q Plumber' Si nature I r/MPRS Number Business Phone Number <br /> �r;w_ C•. -`7`t`1,} I J 2 2- +92_ gZc., .623• ` I- <br /> Plumber's AddresslS[reet,Ciry,�Gta��Code L1 -j cd �„ 5-3 --A <br /> V111.County/Department Use Only �� <br /> Permit Fee Date .sued Issuing A, <br /> Approved ❑Disapproved S egp <br /> ❑Owner Given Reason for Denial /gb b _/■-∎-=. /; <br /> IX.Conditions of Approval/Reasons for Disapproval TT <br /> I <br /> Auach to complete plans for the system and submit to the County only on paper not less than a In:I I inches in size <br /> • berg` 1 L 2 <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />