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<br /> •,..7 _., A. _ f,29 WIM1 fling o IA ., P_E:O. 71162 Sanitary Permit Number(to be filled in by Co.)
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<br /> 1,. r- Madison,WI 53707-718
<br /> - I '' '''''PS " 1,..s.„....„- — scANNED
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<br /> . . I 3 -201C-66 IS-c.,
<br /> 1;i MAY 2 0 2015 li.-,)'
<br /> Sanitary Permii.YA"p' plication
<br /> 1 State Transaction Number
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of 7O-trtTricittieTaffOFii i. governmIntal unit
<br /> is required prior to obtaining a sanitary permit. Note:Application rms for state-owned POWYS re 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 (1C r it e 1-- Rd
<br /> Property Owner's Name
<br /> t,,...e
<br /> &Iv P -Roef Parcel#
<br /> Property Owner's ailing Address
<br /> Property Location
<br /> 5( '3 to r-k*,5 Ka A / Govt.Lot
<br /> City,State Zip Code Phone Number 3 t. 'A, 5A/ v., Section 1'I
<br /> -/-A kl,f 5 .s-.( 6- (circle one)
<br /> T e N; R 4 E or W
<br /> II.:1115pe of Building(check all that apply) Lot#
<br /> e/ ....3
<br /> ,jiLl or 2 Family Dwelling-Number of Bedrooms Subdivision Name
<br /> Block#
<br /> 0 Public/Commercial-Describe Use
<br /> CI City of
<br /> CSM Number Village of
<br /> 0 State Owned-Describe Use CI
<br /> awn of /114 %t)044/./../12.,
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. .r .rw System CI Replacement System CI Treatment/Holding Tank Replacement Only rj Other Modification to Existing System(explain)
<br /> . _
<br /> -
<br /> List Previous Permit Number and Date Issued
<br /> B. CI Permit Renewal CI Permit Revision CI Change of Plumber 0 Permit Transfer to New
<br /> Before Expiration Owner
<br /> - IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> ,
<br /> ..,„ Non-Pressurized In-Ground 0 Pressurized[n-Ground CI At-Grade Mound 24 in.of suitable soil CI Mound<24 in.of suitable soil
<br /> CI Holding Tank CI Other Dispersal Component(explain) CI Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal,ArkaAequired(st) Dispersal Ar6g osed(st) System Elevation
<br /> (ii>P O. io. 13,-... ) 1I 4. 14,4-0 p...)pc_./ .4e-f ---- / ,,Ir
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> 1.)
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks
<br /> at: U C/) 71 C/1 i.4 a a:
<br /> Septic or Holding Tank ) a s4. iA84. ( nee-Ade a .
<br /> Dosing Chamber 86-z.) a b o I
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) tiunib-_'_._ '.4 tut.: MP/MPRS Number
<br /> STEVEN R. CROSBY
<br /> / 227009 608-849-8771
<br /> ,..-
<br /> -,1W_INIIP
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7361 DARLIN DRIVE, DANE, WI 53529
<br /> VIII.County/Department Use Only
<br /> Disapproved
<br /> . pproved CI Permit Fee Date Issued Issuin ent Signature
<br /> V4 Or....—
<br /> 0 Owner Given Reason for Denial /2 76 ---- -5-az-is "1- /re ((-
<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 x 11 inches in size
<br /> SBD-6398(R. I l/1 l)
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