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__ County <br /> s.a Safety and Buildings Division ( jfi�e <br /> / Nx 201 W.Washington Ave.,P.O.Box 7162 'Sanitary Permit Number(to be filled i,by Co.) <br /> .i. A Madison,WI 53707-71E2 <br /> vat i 3 „ cI <br /> ` ' Slaw Transaction;lumbo: ------ .. <br /> Sanitary Permit Application <br /> In toconknee with SPS 333.21(2),Wis.Adm.Cock,submission otthis form to the appropriate goy:ramcnul uni: a (if diffnvt than mailing address) <br /> is required riot to obtaining a sanitary permit.Nos:Application forms for state-owned POIYIS ate submitted to Project Add±v;; <br /> the Department of Safety and Professional Senses_ P erwnal information you provide may be used for secondary <br /> Eirposesinaccordance with the PrvaoyLaw,s.15.41(1)(m),Sotl. - Ill-}-lFelL r..',525,t- 4�1� <br /> L Application Information-Please Print all Information 1 P�.I r <br /> Property Owner's Name <br /> 1-.'L+.r.3j- �i -t'{7�L‘- C) <br /> ---)AME-_, LJ -C! .)/,ft_�A Pn x r}Location <br /> 1'mw:try Owner's Mailing Address <br /> + ' GvuL Lot <br /> ',U7 `�tPLG �= i <br /> Cy,SSSYo Zip Ccic Phone Number W 6V Nb� '4, Sedan <br /> (circle one) <br /> �'' i .��J S (+'' N. P.�i Eur3S' <br /> Lot= <br /> ,t�l.Type of Building(check an that sppl vi i ju:�iv�sion N7-2.1C C71os^2Family Thvctling-NunvlYrofBc ms '`'+ ! .-- - -__ .� <br /> Bink ti __ <br /> D PublidCommereisl-Describe Use_ ❑City of__ <br /> csm Number ❑Village of <br /> — <br /> D5ar Owned-DescriheL'sc -- F-''alA - . <br /> (1 TPtm of_V ` <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 Tronnent•'}tolding sack Replo emcerOnly i' D Other Modification to eistms System(explain) <br /> New System 0 Replacement System <br /> - -- � list Precious Frntit Number and Date Ial'ued � <br /> 0 Clues a of Plumber 0 Pouch T rsnsrer to NewB. 0 Permit Rcnewal 0 Permit Revisiong <br /> Before Expiration Owner ; <br /> 111 <br /> IV. p e of POWTS stem/Com.onent'Devicc: (Cheek all that a'a ) <br /> ❑Non•Presswizcd In-Ground 0 Pressnrired to-Ground 0 At-Grade 0 Mu.Lnd_24 inof suitable soil 'Mound 2.1 is of suitablcsoil <br /> ❑Holding Tank 0OlacDisxsal Componcrd(explain)— <br /> Prettwtntcni Device(explain)V.Dispersal/treatment Area Information: <br /> Desimn Flow(DA) Design Soil Applleaden Rstc(cprk) Dispersal Area Required(of) Di.spernal Ars Proposed(At) 1 Ses em Elecstion <br /> d.pv0 if_`r�G% <br /> LCCr <br /> VI.Tank Info Cepain <br /> u \a,utnt=r <br /> "rr1• oas Units Gallon; u _ <br /> A Nosy Tarda ttisdo=Tulz U - <br /> u <br /> F u J re en •-ty P. <br /> Stryi:or Hording Till: i 1-??i 1i?i'L- I I I ME./'CL:. <br /> Y <br /> r. g t7+,,c.*.; I L1=2 f7 1 — I C+--1J i I I-.5 J\LZ: `` <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown- •14P'MPRS on the nit hed plansBtuineosPhone Nttmttcr <br /> Pis�er's Name(Print) Plumber's Sieranrr ri <br /> b'sdltLv Vv• k'It8"tltc72 L <br /> Plumber's Addnnt(Strxt,City,S-�,Zip Code) <br /> IQ,; CT/ 1-2-1.)., 1'L. bNik.'J ' CE , V-,1 5>'_,a') <br /> VIIL County/Department Ilse OnIV IDs ed lice Agent jiwaeenA0Pcrm=t Fee ���� ' <br /> Appros•ed 0 O nerGive j I <br /> Owner Given Reason fur Denial _ 1 . 1J' <br /> IX.Conditions of Approt'aIReasons for Disapproval <br /> S(A(Pk 17 l`(VJtlAt:.(` �. 4\kt. '\c c ' ill 0C N 6 us o4e,. .a-tsb .,,\-vA, <br /> • <br /> • <br /> ` .tima:b to complete plans rot tie system aur'schema to the[-cooly ocly on!aper not less than 8 L2 c 11 t sch to ire du <br /> SBD-639k(R,11/11) <br />