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-3'.3) 021 0/1 I/4 6' 51,444 61 f*- <br /> r'_` County <br /> Safety and Buildings Division (_)A t`E"_ <br /> ite 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 ' pl Madison,WI 53707-7162 <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 arc 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 e W6>tZ G �'ZJv <br /> purposes in accordance with the Privacy Law,s.15.04(0(m),Stats. <br /> L Application Information-Please Pilot All bformation 1ePzCz•of 4v l)-c>0. <br /> Parcel <br /> Property Owner's Name <br /> PA-r>zine, PAI"(Z.itAA tote L.r- c).707- i l I-4-1V-10-r-{' <br /> Property Location <br /> Property Owner'stt}} Mailing Address <br /> �2 ? Ni(X.('-Cat's`1 1-\11G- Govt.Lot <br /> City,State Zip Code Phone Number s_ /,,WE 1, Section I( <br /> (circle one) <br /> {\ridi�iLGehl t t,1i 17)."').70A T"7 N; R 7 Ear-W <br /> IL Type of Building(check all that apply) Lot r Subdivision Name <br /> Ell or2Family Dwelling-NttmberofBedrooms <br /> Bleck m — <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑Village of • <br /> ❑State Owned-DescribeUse ©Tovmof c-goS' R t\t rvr <br /> 4-11;»,i <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ( `New System ❑ Replacement System 0 Treatment/Holding Tank Replacement Only ❑Other}Acidification to Existing System(explain) <br /> El of Plumber ❑Permit Transfer to New <br /> Owner <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑ Permit Revision <br /> Before Expiration <br /> IV.Type of POWTS System/Component/Device:ce: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade El Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) <br /> El Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Dispersal Arca Proposed(sf) System Elevation <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dis P System <br /> r ' 1• >> r <br /> t c7,j -1,-(•;',r13 <br /> E:tE' f .: 'r d - <br /> 1 <br /> Capacity in Total 0 of Manufacturer <br /> VI.Taut.Info c O " <br /> Gallons Gallons Units I- vTA <br /> New Tanks Lusting Tanks a.O in tri m w G c <br /> Septic or Holding Tank (2 -x. {.e!•`'Y I 1 IVIS- et-1^ <br /> Dosing Chamber tr.:;c" .- f-La'- 1 t•tYs1,13 t(. <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PO\VTSSssh�RS Nuon e attached lber Baniness Phone Number <br /> s. <br /> Plumber's Name(Print) Plumber's Signature l <br /> I <br /> Plumber's Address(Street,City,State,Zip Code) \ <br /> 0-211 (Tl, ('d). IL l' t.U-rv9-I!f-a t{r•,‘i �S2.,51--} <br /> VIII.County/Department Use Only et-. P)1 t l%t-t. ?s'' 1)-2-0 •'--f - <br /> Permit Fee ,t Date Issued Issuing Agent Signature n <br /> Approved ❑Disapproved $ -it Lift ),"w, � �!r/�1 .4/'s-L . <br /> 0 • <br /> Owner Given Reason for Denial <br /> C� x'31'7921 15� Y ' <br /> IX.Conditions ogRpproval/Reasons for I}isrPRQPER TANK SERVICE ACCESSIBILITY•I <br /> ENSURE <br /> Vertical Distance Tank Bottom(s)to Service Path <br /> Horizontal Distance Tank(s)to Service Pad: ft <br /> I 11 fiches In size to <br /> Specific servicing mechanics must be provided*vertical is>15 feet'j <br /> horizontal is>150 feet,', <br /> SBD-6398(R. I1/i 1) <br />