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i�uript`, County <br /> /,/ ' Safety and Buildings Division jJ Ct( -- U . _ <br /> ./Z.-0:"- �,' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> ro Madison,WI 53707-7162 <br /> '��`:::=4" - 3 don- 00/64 94k <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(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 Service. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(nt),State. f^' U{ 3'7 L) 14tei `�V1 . <br /> I. Application Information–Please Print All Information _ i t <br /> Po me Parcel if <br /> {a rshe 4 (((C(CL <br /> (t(4-Lo 05/09017 - ib� - Lk - -o <br /> Property Owner's Mailing Address Property'Location <br /> I l t( (QA,( ..(- <Sk . Govt.Lot <br /> it State, Zip Code <br /> C� Phone Number y, /. Section <br /> -a 1 ( L. 9 -ls (4,0 --eo C( <br /> — <br /> f N; R (circle one) <br /> II.Type of Building(check all that apply) Lot It E or W <br /> YiI or 2 Family Dwelling–Number of Bedrooms '377 Subdivision Name / <br /> Block# G ( L f� .'u.t� h-/lc{ <br /> ❑Public/Commercial–Describe Use <br /> ❑ City of <br /> ❑State Owned–Describe Use CSM Number ❑ Village of <br /> J <br /> KTownof ED X J , <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only KI Other Modification to Existing System(explain) <br /> k r 0/9r7 r°L <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration ! Owner <br /> l 1 t <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ 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) ❑Pretreatment Device(explain) <br /> V.Dispersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> V1. Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units .D °to u rt., <br /> New Tanks Existing Tanks 11 o ei ` i '' V> <br /> C.'U cn n v> a. D .-.. <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume resp 1ssibiti for installation of the POWYS shown on the attached plans. <br /> Plumber's Name(Print) Plum 's,Signatur'e J'/ MP/MPRS Number Business Phone Number <br /> Mike_ 6�r r3 II / G '' /19204.-6\ c ' e/.3-2-, 4:4 <br /> Plumber's Address(Street v,State,Zip Code) <br /> (a 7) i 6 r ‘t i <br /> (11/ _14 t, I,cTi c 3C-79 <br /> 1k County/Department Use Only <br /> Permit Fee Date Issued Issuin nt Signature <br /> Approved ❑Disapproved $ �1 / 6/� <br /> ❑Owner Given Reason for Denial 04/03//7 fe <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> f/v iretifw 7 t ris/wic e 0,arm */r y 5 Ysr,4. f ¢y £Oe'4' ..� "Wee c a <br /> 6907/leilf fse/e . Peet? t>gESTeie7meti L/Si/TM'G. Pi""eBeeole di" Mea°6�b°"" f/r✓ tlY4- <br /> h�rt►t Mast /3r +Aeeteoeo Pewg R. Fi�ri-./,r1#ea/d•'t>, ,C E t! <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 in z 1 inches in size <br /> JUN 0 5 2017 <br /> SBD-6398(R. 11/11) SC R LL Public Health MDC <br /> Environmental Health <br />