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^` nri County <br /> :a,1lI " , Safety and Buildings Division l� e Fr <br /> i ; p 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SP �') Madison,WI 53707-7162 <br /> \. s 2d(�_ 0013 `7 <br /> ., 4� 1 ;n — ..(-tL Valc �;;' 13 <br /> �'{ State T`apsaction Number <br /> Sanitary Permit Applicatiax 1 ! 11 <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the pl:Iiopriate rye �j ! I i)i <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-4 {nyd;PO Wae sdbrt ittedit6'4 Proje t Gress(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide day be used for secondary i i <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 1 L___ ___ --. <br /> I. Application Information—Please Print All Information I F1_,`.:'._ r":`;''t' ''.�' ' <br /> Property Owner's Name — `1 -- . Pium i d <br /> 114,-A "-C:1 es G CYO F— 67 8 •6b —y <br /> Property Owner's Mailing Address J Property Location <br /> x7 7 a 5 Ka 6-4-is , V;/(e ! Govt Lot <br /> City a Zip Code Phone Number A/&), $- y., Section 7 <br /> o S 1 A/,7 �a.6- 5 (circle one) <br /> l / [l T (j N; R Clf E or W <br /> H.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑Village of .� <br /> ❑State Owned—Describe Use �.� t. <br /> *town of I,s i r w'1 <br /> III-T e of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. :lew System acement System ❑Treatment/Holding Tank Replacement Only f5.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 /> i-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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> '15o 6 : 4 J/2 5 (c9 75 se_m _ <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units t c 9 <br /> New Tanks Existing Tanks u o u ? ? T. <br /> Septic or Holding Tank 5D CQ /Z, �D I Nt2_e_____Dosing Chamber 6 /_C G� <br /> VII.Responsibility Statement- I,the undersigned,; . e r •onsibility for installati., of he POWTS shown on the attached plans. <br /> Plumber's Name(Print) P ' Sift e`/ MP/MPRS Number <br /> STEVEN R. CROSBY 41r_ - - 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 /> Permit Fee Date Issued Iss ' gnatur4 <br /> proved ❑ Disapproved $ ��1 11,;% s ��-. �r <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval /I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x tt inches in size <br /> SBD-6398(R. 11/11) <br />