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t,„,r� r`-, County <br /> ; Safety and Buildings Division Di -..i P-,'i,t- <br /> 'ir`. Q 1, 201 W.Washington Ave., P.O.Box 7162 Sanitaiy Permit Number(to be filled in by Co.) • <br /> 'A.-;,.,_`,_ sps 1 Madison,WI 53707-7162 <br /> .mar. <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 Ro <br /> Property Owner's Name Parcel#i <br /> DAvIo bEetat c A-7-4-I E tNE Koss c e( -_)')3 - 6_33c. D <br /> Property Owner's Mailing Address Property Location <br /> 6r1OS V ILLPVC/E PA P—g, Ci2■• Govt.Lot Q <br /> City,State Zip Code Phone Number rT y,. Ni W 'h Section A-f <br /> ',1 I 7(8. (circ one) <br /> MAD I SOnI VlJ T ? N; R E r W 11.Type of Building(check all that apply) Lot# <br /> tVor 2 Family Dwelling-Number of Bedrooms I Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number (�O�/ 0 Village ofa n ^� <br /> 131p6.6 J 6 flown of 8.1404 - EA�`'+ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Re p lacement S ystem ❑Treatment/Holding Tank Replacement Only ❑Other Modification cation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> qSO /'0 45d 950 TO37 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units II 2 <br /> • New Tanks Existing Tanks e c 2 -n F <br /> o U in in to wt7 w <br /> Septic or Holding Tank 1 000 1000 I 1 l W t I, 'E J <br /> Dosing Chamber 600 boo 1 `�_ / <br /> / <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's Signature MP/IvIPRS Number Business Phone Number <br /> -16M LI H lent I3gOi bog 7L1- (-1-g <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -P) la-- s ' Po>z-TFt E1 lAil tg01 <br /> V1TI,/2'ounty/Departmea t Use Only —��'J,AAppproved ❑Disapproved Permit Fee Datee Issued�p Issuing a //�� <br /> ❑Owner Given Reason for Denial <br /> $ y(' �/�/�a w�/ <br /> IX.Conditions of Approval/Reasons for Disapproval fff <br /> T'OTT e r Moe.v4 5 TE 4 Po 4v<-f- /.5-' ,Dor•71/Sd-c'PE //'v /rS A/.4-7-6 U€.#C e t'Of77per• <br /> kb ea medic Tr,wr -P6rcl¢R -.'(C, E+r'4vefnavy, vle- '/e`H/es. rAi-PFtc <br /> _1.S t,t a•u d <br /> I Attach to complete plans for the system and submit to the County only on paper not less than 8 1l2 111 Inches In size <br /> SCANNED <br /> • <br /> SBD-6398(R. 11/11) <br />