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�.e,manr\1 il ((0. Vi ux r-`1} County <br /> 0 <br /> �} Cou <br /> /o°i ;. �y\ J I-'- __ .. - Y Ltd; uildings Division c� O -tr:G - - — - �, <br /> f:'/ S 201 VI Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ■,,r�\, :` '$'� l'il id + MAY 2 6 20'5 ! II Madison,WI 53707-7162 <br /> ♦�4 --- i Li'i L.1 2) ///� 00/57 <br /> Silitary P,6r t Application State Transaction Number <br /> En accordance with SP .as.ii <br /> (2),Wis.Adm.Code,subirdsSintrafmis 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 /t'o ' . IC 6' <br /> P oceerty Owner's Name. j ) Parcel# <br /> IL. fL 11`Q,�f'� /lNf 0' AO 113 J O7// 'A7 ( — Vi/5"- "C`� <br /> Prope Owner's Mailing Address Property Location <br /> PrtY —.. - <br /> 7t� 7 /�T/e4 /. r t r , V Govt.Lot <br /> City,State Zi.".. Phone Nurtiber $w '/., NC '/. Section Ps 7 <br /> Cr)17/9 r a ra ve °" - ' ( (circle one) <br /> T 7 N; R /( EorW <br /> Type of B�iilding(check all that a! . Lot ft <br /> ® I or 2 Family Dwelling—Number of Be.x oms `J .1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number El Village of <br /> ' -3 ?of 0 Town of eci 11-Q--3 e Growl <br /> III.-Type of Permit:-(Check only one box on line A.-Complete line B if applicable)- <br /> A. 1 r <br /> New System ❑ Replacement System- ❑Treatment/Holding Tank-Replacement W t,_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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil El 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(sE) Dispersal Area Proposed(sf) System Elevation <br /> 75-0 / `l /Ff7 'S /e 44 /112.9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units '= $v <br /> New Tanks Existing Tanks 2 g i IA <br /> a`U CO CO wO .. <br /> Septic orltvlthisg Tank 16 5,b /65'0 / /lie Q e9-e i <br /> Dosing Chamber g 6 0 --- gQ U mead <br /> de <br /> VII.Responsibility Statement- I,the undersigned,JIssumf'res on ',ill% ,r Ins i n of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P tuber's re / MPMIPRS Number <br /> STEVEN R. CROSBY c 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 Permit Fee Date Issued , _Issuing ti., a e <br /> .>. <br /> ❑ Owner Given Reason for Denial $ y3 / 5 �' <br /> IX.Conditions of ApprovaVReasons for Disapproval j <br /> A_77-gC(4 ..r.,(6 E� 4a 4-*ay 7. o f /47 -- 0 q <br /> Fog. 01h Pewee__ 4 07((-. 271— q00=7= .: . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/z s 1l Inches In size <br /> ■ <br /> SBD-6398(R. 1 1/l l) <br />