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vE`""--"e`vr County <br /> \ a <br /> x, \",, 1 sp Safety and Buildings Division , awe_ <br /> SP L 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> s'. l"i �+�cfr Madison,WI 53707-7162 <br /> %s' 3�► i3-?,-oLS -oatoS <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 ht. .rn <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are 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(11(m),Stats. <br /> I. Application Information-Please Print All Information 6P/'q u 41 x',.f <br /> Property Owner's Name Parcel# (c/4a <br /> Jtco s/CICe30--z <br /> 'TO SA uct 54,akrs <br /> Property Owner's Mailing Address Property Location <br /> / <br /> L�O o r7 a i re ih Weal/ o- ( Govt Lot <br /> City,State / Zip Code Phone Number S 2 v.,.$w v., Section A <br /> ✓)l p wr }- lap evs (,v .17 7 9 (circle one) <br /> II.Type of Building(check all that appl Lot# T L N; R E or w <br /> l or 2 Family Dwelling-Number of Bedro4ns / ( Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> i C` rl C' ®Town of Ofud J�lcunst) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. %New System ys 0 Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that a ply . <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) / ` ❑Pretreatment Device(explain) • <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 4ov C.� � I,e.cc 600 /a's C <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units =' <br /> C <br /> o u 6 E _ y <br /> New Tanks Existing Tanks n°- .- a ai 2u 1 `� <br /> a U iii., Vi iz o a. <br /> • <br /> Septic or Holding Tank / 7-6 677,-, / /H F a d t .t- <br /> Dosing Chamber <br /> y0 c• Boa _ Meade' 'f <br /> VII.Responsibility Statement-I,the undersigned,assul rcs spasibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si_.'. MP/MPRS Number <br /> STEVEN R.CROSBY /j 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) ,ice I <br /> 7361 DARLIN DRIVE,DANE,WI 53529 •- <br /> -- <br /> VIII.County/Department Use Only __ <br /> proved ❑Disapproved Permit Fee Date Issued /`Issuing Ag \ <br /> S ` ,,,,.../ ` <br /> ❑Owner Given Reason for Denial 1 2 p.^ �/01•47—/-> \ 1 <br /> IX.Conditions of Approval/Reasons for Disapproval i <br /> f <br /> V <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 its a II inches in size <br /> SBD-6398(R. 11/11) <br />