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comma •: wi.gav Sa and Buildings Division County /� <br /> ill - f 201 W. I ngion Ave.,P.O.Box 7162 DANE /r <br /> . it) " 1 i-TE.Vrill V E 'Thl <br /> SC . I i 'RP 1 0 2014 N bn,WI 53707-7162 sanitary rmit Number(�o be filled in <br /> Department • Cornmeros / v �' 0/ —0004 <br /> Sranit P PAP ttf 1jcatjon State Transaction Number ��JJ 8'7 <br /> In accordance with a.Comm.t3:91 ''r.,.i o."' ib'"g(d p ---------"—• <br /> � .Adm:Cdde,°su mi nbfthis�t5cm to the appropriate governmental <br /> unit is required prior to obtaining a sanitary pounit_ Note: Application forms for state-owned POWTS ere Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.040)(m),Stars. STAGECOACH RD <br /> I, Application Information—Please Print All Intbrmatlon <br /> Property Owner's Name Parcel# . <br /> JAMES SMITH& PATRICIA MULLINS 07071122.24034 <br /> Property Owner's Mailing Address Property Location <br /> 610 LEONARD 37 <br /> Govt.Lot <br /> City,State I Zip Code Phone Number NW Ye, NW Y., Section 12 <br /> MADISON Wl 83711 tCheekOnel <br /> II.Type of Building(check all that apply) Lot ti T 07 N; R 07 ri E 0 <br /> 01 or2 Family Dwelling—Number ofBedrooms 4 Subdivision Name <br /> OAK VALLEY ESTATES <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number Village of <br /> Town of CROSS PLAINS <br /> III.Type of Permit•. (Check only one box on line A. Complete line B if applicable) <br /> A. ' ❑✓ New System ❑Replacement 0 Treatment/Holding ank Replacement Only pi Other Modification to Existing System 8 P Y L1 B Ys (explain) <br /> System <br /> B, p Permit ❑Permit Revision ❑Change of ❑Permit Tntnsfcrr to List Previous Permit Number end Date Issued <br /> Renewal Before Plumber Now Owner <br /> Expiration <br /> IV.Type of POWTS Systom/Co ponent/Devke: (Check all that apply)_ <br /> 1 A Non-Pressurized In-Ground U Pressurized In-Ground ❑At-Grade U 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(sf) Dispersal Area Proposed(at) System Elevation • <br /> 800 0.3 2000 .11016- 2/30 J 104.0-108.0 <br /> VI.Tank Info Capacity In Total II of Mamrtbcturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Styli,'orHoldtn$Tank ' 1286 r— 1286 1 MEADE Prefab Concrete <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the tinders( ed,ass ..nsibi for tnstallntton of roe POWTS shown on the attached inns, <br /> Plumber's Name(Print! Pi s Sl:r ri, .MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY ♦ 227009 f 808849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DR. DANE WI 83829 <br /> VW.County/Department Use Only <br /> Approved Disapproved Permit F Date Issued issuing gyp tenor / � t <br /> ,_Owner Given Reason for Denial S j f j •^� g q/��! <br /> '7V <br /> IX.Condillons of Approval/Reasons for Dtsa royal <br /> r A?�itu At �.t ,2 c* , O49 .arc- 7&.r7 <br /> Attach to comptete plans tbr then stem and submit to the County only on paper not less than$v2:11 Juba in she <br /> ChX— ‘g,5-9\5 <br /> SBD-639$(R.01/07)Valid thru OM <br /> • <br />