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/'/� ~r\ County r �1_ <br /> /. , \:� Safety and Buildings Division 06 n-2 <br /> �s/ s )11 <br /> ` 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,I •r 1 Madison,WI 53707-7162 <br /> Yt��� t3Z01s -�J082 _ <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)(m),Stats. <br /> I. Application Information-Please Print All Information C-Oty /tit,-� Y <br /> Property Owner's Name Parcel 14 J <br /> ill Atha n rn�e117 090 '2 -/d3 - 93. 6 - 7 <br /> Property Own'er's Mailing Add ss ��JJ Property Location <br /> 41 ot, [.{).1° '�"tW f f d C4 itet Govt.Lot <br /> City,State f Z' Code Phone Number $to /, S Lu �/, Section / 9 <br /> M u'�urir-u vt I'e. to..1" 5-35-6 6 9 (circle one) <br /> T l N; R 7 E or W <br /> II.Type of Building(check all that apply) Lot il <br /> ®1 or 2 Family Dwelling-Number of Bedrooms <br /> !.�/ Subdivision Name <br /> Block if <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of p <br /> ® ten Town of n tL h u f•y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 1, .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 /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> jia 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6.0 (r I r lA-00 f.cvo o <br /> fll, 7 74,9 7'. <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units g cg <br /> New Tanks Existing Tanks 2 c �' 8 1 <br /> U rnm in t.V a. <br /> Septic or Holding Tank , A-V'C /Arc r m...,,,,i_../ OC <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume res nsibility for installation of a POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's,Si re /6------ "' -- MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved <br /> Min Fee Date Issued issuin nt Signature <br /> ❑Owner Given Reason for Denial 4--5- f s \- rr r , („0 <br /> �� <br /> IX.Conditions of Approval/Reasons for Disapproval ECEIV E D <br /> APR 0 S 2015 <br /> Public Health MDC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Efaiirenromr;rta) Health <br /> SBD-6398(R. 11/11) <br />