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04/: 8/2015 07:58 FAX 6088506848 Septic Specialists a001 <br /> --�-, _ <br /> County <br /> • <br /> /,..27-�ti,Arr s . *.1 Safet!and Buildings Oivision D4 At d -1:f3'..-- <br /> 1 ,4i,!,. ;• 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be Sited in by Co.) <br /> '\ ��5 ���� Madigan,WI 53707-7162 <br /> \' 13 2415—ea3 71) <br /> Sanitary Permit Application stare Transaction Number <br /> In eeeardente with SPS 38).21(2),Wu,Ads.Code;submission of ebb ibtm to the appropriate goveremurral uait <br /> is required prior to obtaining a sanitary permit. Note:Applicadoa trims for staraowtted POWTS are sub mined to Project Address([f diEtuent than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provido may be used for secondary <br /> I purposes in acccrdance wit the Privacy t.aw,ss,15.04(1)01).S is 3 <br /> I. App[Ica tion Information-please Print All Information '' 1{te,4,4441 ,;^f _i <br /> rr ro D ty Ovr.er'a Nome - Parcel Y <br /> 1 r e-n��e.r )�14 d r S t 1-/VC 070$- t93- )61f/.- <br /> (�Property Owtser's Mailing Add= `- Pseperty Location <br /> 10 D /v Ili lt'S�,k� /- S r!,'f a d/ Qm Lot <br /> City,,.State ZIp Code Phone Number A/4/y, 0(</y, &atom /9 <br /> ttAUnA. 14ae ici1.- 53..5"97 T ? _N: R PI or w <br /> Type of Building(check all that apply) [.ot0 <br /> al or 2 Family Dwdlig-Number of Bedrooms apply) _ subdrrivision Note 1 <br /> Block a "' ' Pit el s,9474 P,r)f- f <br /> o Pubtideommeraal-Describe Use — <br /> ❑City of <br /> G Stale Owned—Describe Use CSM Number ❑Village of <br /> ;Plows of ).s 4Q1)a 47,•t.' <br /> rii,Tpa oFfermit: (Check only one boar on Use A. Complete line B it applicable) <br /> A. V Syett n 0 Replerement System ❑TrcatmtntiRoldieg Tank Replacement Only 0 Odra Modification to RakingSysttaa.(exPlaln) <br /> B. ❑Permit Reaawal ❑Permit Revision ❑cbattgn of Plumber ❑Permit Taineex to New list Preelora Pernik Plumber artd Dare issued <br /> Befoor Expiration Naar <br /> . IV.Typrk of POWTS System/Componeat(4evteet (Cheek all that apply) <br /> '':,e on-PremuriZed In-Otouad 0 Pressurized rn-Ground ❑At-Orade 0 Mound?24 M.of suitable soli ❑Meoal<24 in.ofateitabla soli <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatmaat Device(explain) <br /> V.DLspersat(treatment Arch tnforoaathor <br /> Design Flow(gpd) Design SoU Apptioadoa Rate(gpdtt) Oispenal Area Reaulsed(st) Dispersal Area Proposed(sf) I System Elevation <br /> (000 a r (re /COQ 'Pt-z- )18-$' <br /> VI.Took info I CApecity in Total #of Mennfacnuer /15 <br /> I Goatna Collets Vain ° <br /> .w Existtrg Tacks g 1 eh-. <br /> a rtIlInnriniiil i 4) t ikre.t,dr <br /> Dasiag ce.o:eerr. -0 U gd(, 5 .4r . <br /> VIL Responsibility Statemeat-I,the soderailroad,assame rrapoasiblUty for installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Ntint) P MPftvWRS Number <br /> STEVEN IL CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,Stain.ZIP o�dC1 <br /> 7361. DARLIN DRIVE,DANE, WI 53529 <br /> I Coun /De• ••• at Use Onl,�� <br /> II* •p f roved 0 Disapproved <br /> Permit Fee{ Data!seined Issuint;Agent S gn••.,.. <br /> _ ❑Owner Given Reason roc Occur S 13\~ x,j-IS <br /> ix Cmditions of Approval/Reasons far l)lsapprovel <br /> • <br /> • <br /> Attach to eaelptoteplass he tun system sod sabmic to the County eery ei paper sat feu ntaa s vs a It led=le atee <br /> Sa0-6398(R. II/11) <br />