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:,gr}�1tgy• <br /> ,� \r�\ County <br /> (i ,T\ � Safety and Buildings Division l�4 n e <br /> g 4/ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in b Co.) <br /> Madison,WI 53707-7162 y <br /> \{WN.**..t.3 <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 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(I)(m),Stats. <br /> I. Application Information-Please Print All Information Ley Hu j 7--r <br /> Property Owner's Name Parcel# <br /> 6rt'ovi. d- Sune55cc Henning RtR -� 33/ - ci,/ <br /> Property Owner's Mailing Address ..� SG d <br /> Property Location <br /> 02 03 7 tit rT v e Govt.Lot <br /> City,State Zip Code Phone Number <br /> 5 w '/a iV E '/,, Section 3 3 <br /> C_h e f-e k (,v 8- (circle one) <br /> II.Type of Building(check all that apply) Lot# T ( N; R / E or W <br /> ®1 or 2 Family Dwelling-Number of Bedrooms II Subdivision Name <br /> 1 <br /> Block# <br /> ❑Public/Commercial-Describe Use " <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> !3 'a5 E Town of Votk <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Ri New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only _ ❑Other lvtodiflatipl i�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 apply) <br /> iii 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 /> DesignFlow(gpd) --Design-Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> boo , q /5-00 l5-o0 ?/.d <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks U <br /> 28 s U n a 8 Al 1 <br /> A. i vi w t7 4 <br /> Septic orHokiing Tank / .---- n <br /> Dosing Chamber /A Q G ea-K e <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 igii MP/MPRS Number <br /> STEVEN R. CROSBY e'' 227009 <br /> 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) ‘----' <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VI .County/Department Use Only <br /> Approved ❑ Disapproved .. <br /> Perri Fee 64, Date Issued [.suing ent ature( , <br /> -27-20/ <br /> ❑Owner Given Reason for Denial s bl 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> --a° r.P« Al Uri P PRy ) Fey•te P'" ?o rs e-c, .___ <br /> sifill roW eta f, mss- PE# IOS 20/4(-• o8Yy <br /> --)Sit f(—'if fi40 U"l 040 r%Q e-6Da /3 "" O 72--33(- ?e9-J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 i I I Inches in size <br /> SBD-6398(R. I1/II) <br />