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�j a—nrr� County N�''' \ � Safety and Buildings Division ,U e <br /> { 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by C . <br /> i P ' Madison,WI 53707-7162 <br /> �o� 13-2O( -1:�2r35 <br /> �41(lN.��� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form p •.•.ri.te overnmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for • P1.gut r a,• Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information yo p • t d eco sr, <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /) � <br /> I. Application Information—Please Print All Information ,J� 2 0 1O C.--LJ ( ("7 / Af <br /> Property Owner's Name Parcel# /f <br /> A b 4 s t o> G h e 1 e <br /> or r c�q� �nVUollc Health MDC d-5`// d i 3 - g 3 y, -0 <br /> Property Owner's Mailing Address <br /> / nmental Health Property Location <br /> /8 .7 4 ,�,..5 0,t s+ <br /> Govt.Lot <br /> City,State Zip Code Phone Number ,g 20 1/4, $Li--1 A, Section r: / <br /> S T d U g�/-v fZ -J 3 fl (circl e) <br /> II.Type of Budding(check all that apply) Lot# <br /> . T �J N; R ! E or W <br /> 04-or 2 Family Dwelling—Number of Bedrooms 3 0,> Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 4,3 7 7 crown of D%..I A...ji iCrr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 6.New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0 <br /> Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of'POWTS System/Component/Device: (Check all that apply) <br /> lirR- <br /> on-Pressurized In-Ground ❑Pressurized[n-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> y <br /> 'I J� 0 , V 1` a5 / 13V 99,1'1 Ja9,0' 144.$ r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units b c v <br /> v g <br /> y 1 ` <br /> o <br /> New Tanks Existing Tanks a . <br /> U G n w V <br /> a <br /> Septic oriial ing-Tank /A 1^ /O$ f <br /> e.4.thp__, <br /> Dosing Chamber {b D tp ' <br /> 10 46 <br /> VII.Responsibility Statement- I,the undersigned,assume re ••nsibillty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber',i't! re MP/MPRS Number • <br /> STEVEN R. CROSBY r . 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 <br /> X Approved ❑ Disapproved Permit / <br /> it Feeao �Date Issued Issuing Age t Sig ture <br /> ❑Owner Given Reason for Denial $ [m 7 3I ' (`21 49(.5 C <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 I/i z l I inches in size <br /> SBD-6398(R. l U1 t) <br />