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—`�°� Safety and Buildings Division V 4 c r'U <br /> ,,-1:-,, ��\ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 <br /> '` ►"' Madison,WI 53707-7162 <br /> ,\``-k 13-2 15—0022 <br /> FErr10N�V <br /> f Sanitary Permit Application State Transaction Number <br /> / En accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> r <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 /> i 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(tXm),Stats. <br /> I. Application Information—Please Print All Information aCIV 2 7D $ <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing MaailingrAddress'J Property Location <br /> t`r / .7 a t rl b Govt.Lot <br /> City,State Zip lode Phone Number /{lie, y., .$ t-'/., Section <br /> 1'it I U/1 d e-1 d fl i , 1, ~ (p.ZS R �circle E onor eW <br /> ) <br /> T � N; <br /> II.Type of Building(check all that apply) Lot# <br /> t or 2 Family Dwelling Dwellin —Number of Bedrooms )' Subdivision Name <br /> Block# 17 4/-rk e 6f/ a <br /> ❑Public/Commercial—Describe Use ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use /e <br /> Town of )t?Al P,'0.--£( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 9icw System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision • ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Si-gon-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7�1j 0. ...:5- I S a c;› /yoe, tr 7. 7 — . 7. s- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ' c !4 g i 1g o <br /> /�}� `�a-U- iii q vi w CD O. <br /> Septic or Holding Tank 1 1.St I( 'Cd ! ' `&/a 4te • ' - - <br /> Dosing Chamber /t5 i p /a�G� / [ 1' V ' <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) )lu . r i 1.11 MP/MPRS Number I <br /> STEVEN R. CROSBY / 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) 411110 . <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> _VIII.County/Department Use Only <br /> Permit Fee Date Issued I in nt Signature <br /> Approved ❑ Disapproved } �} <br /> ❑Owner Given Reason for Denial EA.31.^ ? 2 -l s " _ i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a It inches in size <br /> SBD-6398(R. 11/11) <br />