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. _r arir\ — County n�� <br /> I x,� r Safety and Buildings Division QCtY4e t{'JL <br /> ,,,`` REC . r `�r Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> C p / / Madison,WI 53707-7162 <br /> ip,�_,...:.- MAY 1 t 10 3'26/.5—(6 /q 1 <br /> teiattan it Application State Transaction Number <br /> In accordance with SPS 383. flrIAPWAPtailleellftion 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(I)(m),Stats. <br /> I. Application Information—Please Print All Information tie h 1 t d e/ ' <br /> Property Owner's Name Parcel# <br /> , <br /> S t'at.r " 1 1 i/ & /?10Or-r-i net hill OW/ --%la2' S))--J5- -O <br /> Property Owner's Mailing Address ./ Property Location <br /> -1 K L' tes`I-h cLue 11 Or'Lye. Govt.Lot <br /> City,State Zip Code Phone Number /U� /, Anti �1/4�, Section ,Z A <br /> e--C/14Q e2_ ,rciv e Lv-Z,.-------- .� .-7,,, (circle one) <br /> H.Type of udding(check all that a!: y) Lot# T 7 N; R /1 E or W <br /> 0 I or 2 Family Dwelling—Number of: drooms 3 ! i Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> 3 3 eo ®Town of C-.0//eve (9. cat..-e <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. m,New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only C,T Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal II Permit Revision ❑ Change of Plumber Cl 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 /> allon-Pressurized In-Ground ❑ Pressurized En-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(si) System Elevation <br /> Y 0-0 •`i //, .T— '/! 36 /oO C ,. — — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D ` 0 - <br /> New Tanks L1- - <br /> Septic isting Tanks 4- o :: 4 u .2 m <br /> n. V vt 71 rn w v Y. <br /> dl tt tdiu Tank /06 , <br /> /60 U 7)2-e es, dP t <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume-re•sonsibility for installat of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Plurpbkr's —., r . 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 33529 <br /> s. <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Iss ' A Si re <br /> , pproved ❑ Disapproved $ J/ <br /> ❑ Owner Given Reason for Denial <br /> y a� s�rel. ,' — C' 4h,f,(5--- \, <br /> IX.Conditions of Approval/Reasons for Disapproval l '� <br /> firy \,.. . . _ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/a i It inches in size <br /> SBD-6398(R. I.l/11) <br />