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}--' ?i i B ''',4%,,j Safety and Buildings Division County. <br /> f 201 W.Washington Ave.,P.O.Box 7162 <br /> l i `' i l':!-L74 Madison,WI 53707 7162 i N - <br /> - F i �. ,�. ) (' t � � ; r � Sanitary Permit Number(to be filled in by Co) <br /> Sanitary Permit Application 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 /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1Xm),Stets. <br /> L Application In ation—Please Print All Information <br /> '`es Parcel# <br /> UALE CVb R 4Ad-)Ee - vsa/a967-O7�{-?O -( <br /> Property Owner's Mailing Address Proper}t'Location <br /> 7Szep i rf /8 B Govt.Lot <br /> City,State k r) VI <br /> Zip Code Phone Number toe e y, Se. /, Section 7 <br /> CS l�LI 1t Ol 1 1 63583 T 3 _ 566 7 T / N; R 7(circle qne) <br /> IL Type of Building(check all that apply) Lot# <br /> rW <br /> ❑fivr 2 Family Dwelling-Number of Bedrooms .3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> O'Iownof X6L 2V <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) - <br /> A. ❑New System ❑Replacement System y p y ❑Treatment/Holding Tank Replacement Only 0-01arAfodification to Existing System(explain) <br /> co/live Cad kf <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner T-41-C: I q-y O S c t/JTy-I Z Z Z'- <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> gig-On-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.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 'S E(Sg o <br /> New Tanks Existing Tanks i <br /> Cg;� U ili 1 wC7 w <br /> Septic or Holding Tank /600 /Ooc ( <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Piper's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> rek r1eNee(`( 247 L 4,63'-6S'3 -28!/ <br /> Plumber's Address(Street,City,S p Zip Code) / " <br /> Esc oti, c� . A/Rte c,U cS4c. (Ai, 5357( <br /> VIII.County/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than b t/t s 11 inches in size <br /> e <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />