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• r:0 -.-1•ri-' Q 1 V <br /> �ro�'1 jt County <br /> r /�/� , r RECEIVED Safet <br /> /X y\ y and Buildings Division na,_�, <br /> i=� s: .' " Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in b Co.) <br /> VA\ ` Madison,WI 53707-7162 <br /> .. —. MAY 2 81115 ` 2 i`3-0(-)`c?0 <br /> swortailfee h <br /> egacituApplication State Transaction Number <br /> [n 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(1)(m),Stats. <br /> I. Application Information-Please Print All Information rteld I)I'9w L&,re <br /> Property Owner's Name Parcel H <br /> Pee/l e's W <br /> i � I Wee, 071/ -1 32 - $-cr00 -0 <br /> Property Owner's Mailing Address/� C Property Location <br /> /0,?- /V- PO,,i IX O j at l✓ J� <br /> e- tyt ft- 1 Govt.Lot <br /> City,State J Zip Code Phone Number <br /> /L l.v 1/4. /V by 'h, Section 3 3 <br /> Li)b u rt.c ic'e e. Gv/ 7 -2 7 T N; R 1/(circle one) <br /> H.Type of Building(check all that apply) 410 Lot ti <br /> IFI-1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block H <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CS/v[Number ❑ Village of " <br /> / �r `� 2 Town of C.-1,511-aye Grote <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) J <br /> A' fit New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only t,31.Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade A Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> k DO 1 y /So-& / Sa RC t <br /> .s <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units 8 <br /> New Tanks Existing Tanks <br /> a °: ° a� �? <br /> v c U ; u , 2 2 <br /> t U in y ti LE 3 ii <br /> Septic orKsieling Tank <br /> l2.8-G — /g$G I Meade oe <br /> Dosing Chamber if <br /> V 6 0 kGb I I'iq,aa,1 te. 61 <br /> VII.Responsibility Statement- I,the undersigned,assume res.onsibillty for install n of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' 't_ `t re MP/MPRS Number <br /> STEVEN R. CROSBY <br /> 227009 <br /> ' 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only —.�, -r- -- .�� <br /> Permit Fee Date Issued Issuing ent Si tune <br /> Approved ❑ Disapproved r L g <br /> ❑Owner Given Reason for Denial $ '���(�'� v -2 2a C 74p4,--- <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> PP7ez-r ft,owtrA PfJ%4A _rit < 4--(O 4 € A- <br /> F' PIL cnr f -ia , fo4 . C?c.c �. ''-4-rO ret taft„ivL 4„ftsc� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 e I I Inches In size <br /> SBD-6398(R. l 1/1 I) <br />