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<br /> -4017:11C4- County,_,
<br /> Safety and Buildings Division U a. /0 Q___
<br /> 201W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by CO.)
<br /> to. 4-.„-,S p..;• Ft)
<br /> Madison,WI 53707-7162
<br /> V.,- , -1.-,-.- S i.:.•;)
<br /> I
<br /> *V-iizi-gfr
<br /> Sanitary Permit Application State Transaction Number
<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 Servies. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name Par,el#
<br /> Ric-K k --SZ\ `s5*. °`)S \\'*-41' \•
<br /> '''`• \ \
<br /> ) , t "060S -0q3-1(130-S
<br /> ..) tli( ,vit 4 v, ,
<br /> Property Owner's Mailing Address Property Location
<br /> ‘1
<br /> va/73 0 \Au t 0, D v . ,
<br /> Govt.Lot
<br /> City,State Zip Code Phone Number
<br /> 5 1/4,9-K/ .A, Section 5
<br /> Ve\-bnic,, wM. S3,s q 3 603-5(-N5 T G . (circle one)
<br /> N. R
<br /> N; Q or W
<br /> U.Type of Building(check all that app] Lot#
<br /> v,/,73
<br /> EJ 1 or 2 Family Dwelling-Number of Bedroo Subdivision Name
<br /> Block#
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of
<br /> ...
<br /> 0 State Owned-Describe Use /
<br /> CSM Number 0Village of
<br /> /7/9 ,,,n Town of 145'f OA)CA,
<br /> III.Type of Permit: (Check only one box on line A, Complete line B if applicable)
<br /> A. 0 New System S Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued -
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> M.Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil El Mound<24 in.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
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<br /> V.Dispersal/Treatment Area Information:
<br /> Desip Flow(gpd) Design Soil Application Rate(gpdsf) pispersalArea Required(sf) Dispersal Area Proposed(sf) System Elevation I o'-I,o'.
<br /> A° CD Lt°0 .fri , I5volgbo Pit.c. 3b. , i , t
<br /> (4., q00 s(L-P-t- (163.5 )ko3. )
<br /> % lea,
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> 13
<br /> Gallons Gallons Units .E.'
<br /> .. o,4
<br /> „!,.)
<br /> New Tanks Existing Tanks ,r,2
<br /> 0,0 iz . .v, tr.0 a.
<br /> Septic or Holding Tank 1 0 0 0
<br /> tD.Ob :ADO 0 D c?;.e.ec xpcx.\merol K
<br /> Dosing Chamber i, 750 -15c-, /
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) -- Plumber'sirre MP/MPRS Number Business Phone Number
<br /> Plumber's Address(Street,City,State,Zip Co%)
<br /> ,.
<br /> k 3 3 0 EN-- A-?___ P.-a . V e_r o c, ,
<br /> ________........_.....,
<br /> ..- _--
<br /> VIII.County/Department Use Only ..,-- _.......-
<br /> \
<br /> Approved 0 Disapproved Permit Fee Date Is .-. Issu'rig Agent Signature
<br /> 14
<br /> )
<br /> $ ' ('''
<br /> 0 Owner Given Reason for Denial 1
<br /> IX.Conditions of Approval/Reasons for Disapproval i /
<br /> UA'iFia (V*A\3tr OVA l(Ni VA &,KiFil twil \ouzi \kA is otst, 0 , tr vit■.4,\06,xe, ;144,1,
<br /> DA )04.1\ to,u,h -.Zt-tA Cp4.
<br /> ,-,
<br /> CIA■Vol i,.4t( WS 0.3.44n cfAi qic, em;■4iel qts vcti.- cok.
<br /> is, c , ,,
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 X II inches in size
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<br /> SBD-6398(R. 11/11) SCANNED
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