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DCPZP-2015-00253
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DCPZP-2015-00253
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5/19/2015 11:13:20 AM
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5/18/2015 1:53:25 PM
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DCPZP-2015-00253
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"er,.aT'v`a;i ' County <br /> I/ <br /> /�;�; ; ,;, T\ 5 b Safety and Buildings Division Carte <br /> $: ( N 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> I' � P ; ~) Madison,WI 53707-7162 <br /> ry. fps, ) 15-03 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. t <br /> I. Application Information-Please Print All Information 6,f Oak /%r-bire. <br /> Property Owner's Name -Parcel# <br /> Or eft) k 6PaI. th L------O FIO - 36q - ?on °b <br /> Property Owner's Mailing Address Property Location <br /> 2-o1 ? IW a,DV ee- -1-7-0-i 1 Govt.Lot <br /> City,State Zip Code Phone Number r/ r— <br /> N� '/., 5 g '/., Section 3 c <br /> Waunakee LoT _ 53$ 17 (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T V N; R /.0 E or W <br /> gi I or2 Family Dwelling-Number of Bedrooms y Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> , V `l' ®Town of (3urke <br /> •III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. El New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Onl y <br /> r:3(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 /> ❑Non-Pressurized[n-Ground ❑Pressurized In-Ground Ig 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) D!/ sal Area Proposed(sf) System Elevation <br /> L l O G 2...- /G o c <br /> /00 o /Oo f <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 8 o v o <br /> New Tanks Existing Tanks w g u U u ... H <br /> ; o 2 E 8 �d <br /> rt U vt . rn iF.O a <br /> Septic or Holding Tank /g V G t' 8,` / <br /> /neaBP ' <br /> Dosing Chamber ,0 V $'D 0 in / <br /> VII.Responsibility Statement- I,the undersigned,assn a roap sibility for instal on of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Pyl m lift s ate MP/MPRS Number . <br /> STEVEN R. CROSBY / 227009 608-849-8771 <br /> V <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuin nt Signature <br /> ❑Owner Given Reason for Denial $ i "`ee'1(` 4-30-/J`�- `/ , e24-1E---e---- <br /> IX.Conditions of Approval/Reasons for Disapproval `A%� <br /> Attach to complete plans For the system and submit to the County only on paper not less than 8 In a i i inches in size <br /> SBD-6398(R. 11/11) <br />
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