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- County ;. 2 F{ <br /> -.5-40; F� Safety and Buildings Division <br /> � ) _ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> sg"f - P }' IA Madison,WI 53707-7162 <br /> � s_ : /3 -son - corn <br /> ��_ .- State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 38321(2),V/iis.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 /> 'I I purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information Parcel# <br /> I I Property Owner's Name /� S�a_ 0-7k(- 95-70-0 <br /> �>QA�� Q-r'�G� Kier-T-1 lJ f�-U F���- _" Property Location <br /> Property W Owner's Mailing Address <br /> 13(06— 1 L W W Govt.Lot <br /> Zip Code Phone Number '/s ''y, Section <br /> City,State I (circle one) <br /> R-11 AJ �� 6---353z-1 <br /> T N; R or NV <br /> ,II.Type of Building(check all that apply) Lot# / Subdivision Name <br /> IS 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use 3-3 ❑Town of <br /> Ill Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A %Other Modification to Existing System(explain) <br /> ❑New System 'jteplacearent System ❑Treatment/Holding Tank Replacement Only <br /> 12-ew 0 oe. .-r <br />• Change of Plumber <br /> ❑Permit <br /> Transfer to New List Previous Permit umber and Date Issued <br />• B. ❑Pee Expirat on ❑PermitRcvrston ❑ g 9 n 5-C / 7 fat(Ie- <br /> Before Expiration �� o - <br />• W.Type of POWTS System/Component/Device: (Check all that apply)jd <br /> � on-Pressurized In-Ground ❑Presses zed In-Ground ID >24 in.of suitable soil ❑Mound<24 in.of suitable soil At-Grade' ❑Mound <br /> ❑Holding Tank -❑Other Dispersal Component(explain) el ❑Pretreatment Device(explain) 1 <br /> V.DispersallrreatmentArea Info rr--lion: Elevation i <br /> Design Flow(gpd) - Design Sold App t;on Rate(gpdsf) Dispersal Area Required. Dispersal Proposed(sf) System <br /> G O <br /> _ ti✓lL �� `, of �, :Manufhcnaer.�ll�tiK �'1'S{ '? J <br /> C„igdty m-.. •Total' o.o <br /> V�L Tsnk nf0 `allons Gallons Units 6 2,s ... <br /> _ New Tanks - Tmo VI Tanks- rye a,U isi - m • u.C7 'P+ <br /> Septic oLileldmg Tank /o e • ��+VO -��� 't <br /> Dosing Chamber ... <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Signs MP/MPRS Number I Business Phone Number f <br /> Plumber's Name(Print) -!�> I i (3 ��'I b D CJ Z 9D-9 �Y <br /> J i C K -�a 11 t.,AI aft_ -� fJ 1 t <br /> Plumber's Address(Street,City,State,Zip Code) 3 ,! <br /> 2 L VU l 1+1- 6-14”J / 7, OD6=e-- --rent) wr I `-f' <br /> VIII.County/Department Use Only <br /> Per-4 r- Date Issued Issuing Agen Si ,/ ^l`r ✓Y�' <br /> pproved ❑Disapproved $ 51 re d(1-7 `�y� LgE'rr 4 <br /> ❑Owner Given Reason for Denial P !� <br /> IX.Conditions of Approval/Reasons. -/Y-,/ac‹ for Dis(ro ei?i9A -�5,1 G� O F 0(l(4- (/(4-- f ,l <br /> 4 Jima,( edwa.rd�so.-1aun�;,, 1 ei)94,10;1. t�-�:-- _ <br /> Attach to complete phns for the system and submit to the County only on paper not less than 8 L2 i 11 inches in size yihl 2B11 <br /> SBD-6398(R.11/11) SCANNED �-,,,,. d,o- <br /> cittl MDC <br /> Environ ental <br /> Health <br /> r. <br /> t <br /> 1 _ . <br />