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r�anr r� County <br /> ky. <br /> t�f '7 Safety and Buildings Division Oan C Zq, <br /> f VII 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' t �a , Madison,WI 53707-7162 <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(1 Xm),Stats. <br /> I. Application Information—Please Print All Information 6t ie- S <br /> Property Owner's Name <br /> Parcel# <br /> CPa"y 43ec.(t d` r<'a.re,t Oenu_ 67//- 63 `J- PYYI- Y <br /> Property Owner's Mailing Address Property Location <br /> W 7 P-// Pa h./t /e1 t?GC Govt.Lot <br /> City,State Zip Code Phone Number 3 <br /> NE�-7 '�,, s& �'A, Section <br /> 19a r c�P_ V i`l l tk S 5 'l SV T 7 N; R //circle one) <br /> II.Type of Building(check all that apply) /� Lot# <br /> �-1 or 2 Family Dwelling—Number of Bedrooms + L Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ®Town of C_'a 1h1c q e i"a v-e <br /> III,Type of Permit: (Check only one box on line A. Complete line B if applicable) ✓ t; <br /> A' 0 New System ❑Replacement System ❑Treatment/Holding Replacement Only g Tank lacement p y 0 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 apply) <br /> FR Non-Pressurized In-Ground ❑Pressurized[n-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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 6.0t' r `l I /5—t i /,S`i'z 145:6 4t..1 i'd.3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks § t <br /> j <br /> E 5 <br /> a.0 '61' t', in w0 0. <br /> Septic oe.l o ding Tank / 2-r G - /a YG ( m ,a�� <br /> pe <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation oft e POWTS shown on the attached plans. <br /> Plumber's Name(Print) • Plum. .:, MP/MPRS Number r <br /> STEVEN R. CROSBY � 227009 <br /> 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> 7361 DARLIN DRIVE, DANE, WI 535 • <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved $erm't Fee Date Issued [ssu'ng A nt ignature <br /> ❑ Owner Given Reason for Denial . IM 5-6 -20/5' <br /> IX.Conditions of Approval//Reasons for Disapproval <br /> cr <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lIZ x II inches in size <br /> SBD-6398(R. 11/11) <br />