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/Al .r.\ Safety and Buildings Division ID o,r�4 a-A <br /> di s ,-‘' s.'' MAY 2 7 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> y� .'- . '� Madison,WI 53707-7162 <br /> \� ,�l;_ / Public Health MDC /3—�'%— 110 <br /> ` ice,,,.-- Environmental Health <br /> - <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(I)(m),Stats. .,t/ <br /> I. Application Information—Please Print All Information V ei hc°'3• 4 („�at�J <br /> Property Owner's Name pm ei# l <br /> Lr'i sty $ 73.e#& V0.7 1,�,- (79/1- 3 43• �4 -U <br /> Property Owner's Mailing Address Property Location <br /> 3167 L tte2 4 f .& Pc-14•- <br /> Ci State Zip Code Phone Number G?.vt.Lot <br /> City, P v' / /4J �/, •S1tf %, Section 3 cl <br /> S V� '?'---21 f-C e 4)-1- <br /> 5 3 6°9 3 T N; R !/rc.one) <br /> H.Type of Building(check all that apply) Lot# az- <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# c Vr1l34-Di 6,0` 4,'j <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ VVi_llage of <br /> 47-wnof Bt; s 4-Q l <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. 'Iew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only 0 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 In-Ground ❑ Pressurized[n-Ground ❑ At-Grade (y 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(gpds D' rsal Area Re 'fed(st) Dispersal Area Prop sed(s System Elevation <br /> 7 _ o,Lf o C1 . \c6( 7 GC$' ion <br /> VI.Tank Info / Capa ' in otal #of Manu cturer I <br /> Gallons Gallons Units u <br /> Now Tanks Existing Tanks W E U y q`� " 'U <br /> y G II 2 y L <br /> U 'cis ea h wC7 5. <br /> Septic or Holding Tank / �q�_ r t ' r �� .� <br /> Dosing Chamber / Q--,�. {g1.f:) I it <br /> VII.Responsibility Statement- I,the undersigned,ass ponslbility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum,-r '• : 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 53529 <br /> VI .CountL//Department Use Only Al <br /> roved ❑ Disapproved Permit Fe (n Date Issued Issuin: 'gent Sig :T,;��MAW� I <br /> ❑ Owner Given Reason for Denial 11���✓ • 6h i j /: wa .i <br /> IX.Conditions of rov easons for Disa val <br /> C 4 .mil c <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i/2 s I I inches in size <br /> SBD-6398(R. 11/11) <br />