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„,,Yzeearg;,-;r, County <br /> -'ri: N;;,\ �V Safety and Buildings Division ) ,/ t N-0$ �_� V' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permmber(to be tilled in by C5) <br /> PS Madison,WI 53707-7162 <br /> , <br /> %, te r% r , ,i' ... <br /> ��'`Ysiort,�/ 1.._-.3 ,g („1,...; }»e3 :.) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(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 info t oc y?re secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats 1+�( '' D <br /> I. Application Information-Please Print All Informati L•• 1-4/124A--C 26 2 /A' Jii'-. , <br /> Pr erty Owner's Name Parcel / <br /> JUN8 - /115 <br /> Pro rty Owner's er's Min Addres �� Public Health 1)4/( ” ; 3^ �'3$S-0 <br /> Property Location <br /> Environmental Health <br /> Govt.Lot,, <br /> Cit State�� ! Zip Code Phone Number �y �s <br /> � .�( '✓`w Sectwn 0 ( cv J4 Cf a (circle one) <br /> T 9 N; R i( EorW <br /> II. type of Z9, <br /> uilding(check all that apply) f� \ Lot# <br /> -4'1 or 2 Family Dwelling-Number of Bedrooms r <br /> ‘ 5- Subdivision Name <br /> Blocky 1I --/0/ (7;4 r� --Al er <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 'a' . not A t1 S 4-Ci ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> s_New <br /> 1 <br /> B. CI 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 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(st) System Elevation , <br /> _ r ),,-1 <br /> VI.Tank Info Capacity in Total #of Man(rfacturer <br /> Gallons Gallons Units o a <br /> N New Tanks Existing Tanks � 2 u � Tz a b N <br /> ` c 2 <br /> Cr. U in <br /> N i:. 3 a. <br /> Septic or Holding Tank l0 8 / q 0282- , �/�`A. Cr <br /> Dosing Chamber 6e)0 -ba ) Y = <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's gna�ure �1 �' 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 /> VI I.County/Department Use Only <br /> Permit Fee Date[ss ed Issuin gt n tgnatur � <br /> pproved ❑ Disapproved � A i / <br /> ❑ Owner Given Reason for Denial / , - �� f . <br /> IX. Conditions of Approval/Reasons for Disappro ,I ' <br /> 5 ` E Ac e <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R. 1 1/1 1) <br />