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1 <br /> !-- - County <br /> i _ Safety and Buildings Division if.11~._ <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> z< Madison,WI 53707-7162 <br /> 13-2021-00198 <br /> • <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information -- U-' .-11,,,t.-( 1.14- <br /> Ptoperty Owner's Name Parcel# <br /> 14:1-=RGI1eL 4L. ti U -23 3 `1,4')x--`7 <br /> Property Owner's Mailing Address Property Location <br /> 10'0 f lc tj > }-1Vi-( 14 Govt.Lot <br /> City,State Zip Code Phone Number SE a/y Si..i '/, Section•;:."5 <br /> VI, CA V_1 IA t ‘,---,\A i 5,;:v"--"i 5 - T _N; R >( circle one) <br /> II.Type of Building(check all that apply) Lot i <br /> 1 or 2 Family Dwelling-Number of Bedrooms_" ! I Subdivision Name j <br /> Block# --- <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use ___ <br /> Er Town of 13i-- -..K- C.:AVM <br /> ,-iCT, 7 1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Ei New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 10Other Modification to ExistingSystem(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner t <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0-At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain)_ _ 0 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 /> t_-t t'' 47.".4, 10 °' (LY t`., riet.c - <br /> VI.Tank Info Capacity in Total it of Manufacturer u c b <br /> Gallons Gallons Units ,r, t U <br /> w U U y d r <br /> New Tanks Existing Tanks o° °.'. b� w g d .) <br /> i _ aV in e yr w0 a. <br /> ISeptic or Holding Tank I :^s %.=ri i {�rl ()F . _ <br /> Dosing Chamber (“-,. C..% -- (:,a'4.,, I IV1E. 'Xt: k= 4.. <br /> VIL 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 IMMIP/MPRS Number Business Phone Number <br /> ter t .; Lv , kle.4 kti2._.. 1.- 1.,,,z___..7------- 2 C1 t<.,� ir� <br /> Y, tit" - i._....-- 1.. <br /> . <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7e`�l L itis. d?_ '-• y cz.t•y .k _t' , t 1 1-3- 5;71" ) <br /> f <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued I Issuing Signature <br /> ®Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial 1360.00 07/06/2021 1 HAr,i/Iirt.. <br /> DC Conditions of Approval/Reasons for Disapproval <br /> Protect at-grade site and area 15' downslope in its natural condition. <br /> No compaction, disturbance, excavation, or vehicular traffic is allowed. <br /> NOTE: At-grade to serve proposed new residence only. Existing shed with convenience bathroom to be <br /> connected to existing POWTS on the property_(permit # 13-2021-00081). __ <br /> Attach to complete plans for the system and submit to the County only on paper not less than g 112 a 11 inches in size <br /> SBD-6398(R. 11/11) <br />