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industry Services Division I County <br /> 1400 E Washington Ave 1 LW...W.. <br /> 1 P.O.Box 7162 Sanitary Penult Number(to be filled in by Co.1' <br /> 1 Madison,WI 53707 7162 <br /> 13-2021-00155 <br /> Sanitary Permit Application State(ransection Number <br /> In accordance with SPS 383.21(2).Wis.Adm.Code.submission of this form to the appropriate governmental unii <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned KAP:l'S art submitted to •Project Address Of different than mailing addressi <br /> the Department of Safety and Professional Services.Personal information you provide stay he used for secondary <br /> • •i ter in mcordance with the Privacy Law,s.15.04(1Xm),Stats. <br /> I.A,,lication Information-Please Print All Information 51../t4124SE (20A-9 <br /> Property Owner's Name Pamela <br /> Vevi it-L.I illki A ri A$.1 A 'CALI,At it,I.,1 C4C,•art 3-ei,i?c, C-, <br /> Platten),Owner's Mailing Address Property Location <br /> S% E. g NY L.Vi c T. <br /> Govt.Lot <br /> City,Stale Zip Code Phone'..riamiscr l•ro•I lb. Sinl 'A Section 1 <br /> ... s--- <br /> .C.APPd.,±3,17)IPS e•--, 414 IL 5,-4-.1 ,,„mock one) <br /> T r'' N: R Ihur4W <br /> IL Type of Building(check all that app Lot/2 <br /> rj1 I or 2 family Dwelling-Number of B 4 ,-.. Subdivision Name <br /> Block 4 <br /> CI PublieiCommencial-Describe Use <br /> - •• 0 City of <br /> CSM Number 0 Village of <br /> 0 State Owned Describe Use <br /> g Town of 1uTT-Al-4C7'. <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> ,----... <br /> A. i <br /> New System 0 Replacement System CI Trooment'lloiding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> t.iat Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber CI Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of PO'iirTS System/Component/I/tyke: (Cheek all that apply) <br /> 0/Non.Pressurired In-Ceound 0 Pressurinei in-(trourid 0 Atv(irade CI Mound>24 in.of suitable null 0 Mound-e 24 in.of suitable soil <br /> CI Holding Tank D Other Dispersal Component(explain) Il Pretreatment Device(explain) <br /> V.DIspersalareatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rateigpdst) 1 Dispersal Area Regained Of) Dispersal Atm Proposed(of) System Elm anon <br /> _ <br /> VI.Tank Info Capacity in Total #of Manufacturer 2 a <br /> Gallons Gallons Units A <br /> ,... .z. <br /> ' New Tasks Earring Tanks 2 i 2 i <br /> _c..; di ii:.rr',.., F. <br /> sere or Holding Tank <br /> rk.:46,g dumber . <br /> VII.Responsibility Statement-1,the undersigned.assume responsibility for Installation of the POWTS shown on the cinched plans. <br /> Plumber's Name(Pont)- Plumber's Signature -- lutP/MYRS Number flimsiness Phone Number <br /> ktiv-i.tei_k, ,...t fveie...V‘i•vc,1.1.. ---4—,‘--L-1 <br /> c <br /> Plumber's Address(Street,City,State lip Code) <br /> 15;1:4) f Try. PA). t ltivki.Lt.fiek.V.Z -4% ri-FC-.4-7-1 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved <br /> Permit Fee Date Issued ;nal A,,.,..gosooc <br /> El S <br /> 0 Owner Given Reason fur Mats] , 440.00 06/11/2021 A <br /> AR .41 itZ2.4e. \ <br /> IX.Conditions or Approval/Reasons for Disapproval ..." <br /> ..,'' <br /> ...... <br /> Amara to mnapkte pines for Ike ayortin and submit to the County 0114 an paper not lest liming 1.2 x 11 ill,II.h.OM <br /> SBD-63.98(R.08/14) <br />