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F s County <br /> „, �\ safety and Buildings Division Q <br /> d/ ;� :� 201 W.WaShingtonn Ave.,P.O.Box 7182 sanItary p spit Number(to be tilled in by Ca) <br /> : ,, r Madison,WI 53707-7182 <br /> // Y3 -.26s --Oc2_ <br /> Sanitaty Permit Application State TotneactlonNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submluion of this tbrm to the appropriate governmental unit <br /> the Department required btaining a sanitary permit. Note:Application Iterms fir state-owned POWTS am submitted to Project Address(Vibrant than mailing address) <br /> Slaty and Proltsslonai Service. Personal intimation you provide tngy be used for secondary <br /> ores in accordance with the Pr! ... Law s.13,' 1,m, Stets. <br /> L A..llcation Information—Please Print All nformatlon vet 6e/ I ' 1 <br /> Property■ .Br's erne Pend , <br /> Oe- ak Tr/ den 1 A (r`i: 7„Ida <br /> Property mar's Melling Address Q?a p'"A03-0Y07-b <br /> Ott Property Location <br /> City, ite q 8 ht e e G e A 9 s Ot t v4 Aovt,Lot <br /> `,U Zip Code Phone Number N(� !� Su. i3, Seethe D <br /> MAdise G <br /> " S 53711 - T. 7 N R (circle <br /> II.Type of Building(check all that apply) Lot': <br /> la 1 or 2 Family Dwelling—Number of Bedrooms .5- /1 7 Subdivtslon Nemo i <br /> Blocky serer de //0 No w <br /> 0 Public/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number ❑Village of <br /> 6 Town of O'ls'date film • <br /> KU.Type of Permit: (Cheek only one box on line A. Complete line B If applicable) <br /> A. XNew System 0 Replacement System 0't'restaurt,HoWin <br /> g Tank Replacement Daly ❑other Modification to Existing System(explain) I <br /> B. 0 Permit Renewal 0 Permit Reviaton 0 Change of Plumber I 1:1 Permit Truax to N e w List P r e v i o u s Permit Number and Date issued I <br /> Betbre Expiration Owner <br /> [V.Type of POWTS Bystem/Component/Devlem (Cheek all that apply) <br /> Non•Preuurized In-0round ❑Pressurized In•Oroand 0 At-Orade 0 Mound>24 In.of suitable soil 0 Mound<24 In.resoluble soil 1 <br /> •0 Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) •• <br /> V.Dispersal/TreatmentArea Information: <br /> Design Flow(gpd) Design Soil Application Ramis/dst) 1 Dispersal Area Requlrod(at) ) Dispersal Area Proposed(it) MElevation <br /> '21'G I Y /SrZr I o <br /> 1514a 3, .3,, <br /> VL Tank Into Capacity in Total d of Manuthuturer q <br /> Oaiam Oaliotn Units <br /> Now Tab tixhNeg Tanks 1 i cl IN SepthcrHoldingTeak 1 �o /G'f'a r <br /> Dogleg Chembee /91 s a d-C a j <br /> too ra01 I Ale ad-e— X- <br /> VII.Reapoasiblli Statement-I,the undersigned,assume ruponsibllity for etallatlon of the POWTS shown oa the attached Mans. <br /> Plumber's Name(Print) I S :,. MP/MPRS Number <br /> STEVEN R.CROSBY I �� 227009 608-849-8771 <br /> I ` I <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> WI.County/Department Use Only <br /> pproved I 0 Disapproved Permit he Date issued Issuing <br /> ❑Owaar Given Reason for Denial <br /> IS �3r Ic3-17(S I <br /> IX.Conditions of ApprovaVReagoae f r Disapproval ' <br /> 3-r-t-/ s - P ode rstr—c � 1- ,..�f c t q3, o <br /> PVt vL.4--e v s� - t:M CA. e j4...4-0,4,./0•- <br /> �Gz`1 ' <br /> Mureh to complete pleas for the system cad tubmlt to the County only on paper eat Ion then a us t I t lade In the • <br /> SBD-6398(R. 1 l/l l) j <br />