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vetAarvti ,
<br /> , t( / �?�n County �4AZ li�
<br /> /�� 'N;,:\ Safety and Buildings Division .
<br /> is 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) '
<br /> S
<br /> ,1 r -1 Madison,WI 53707-7162
<br /> -,„,N, 13-.x►s-062,517
<br /> Sanitary Permit Application 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 Vmk'V� X`,e
<br /> Property Owner's Name Parcel#
<br /> /sn-a. Id /re..,- At-t 6 91/, 563,637 -6
<br /> Property Owner's Mailing Address ( Property Location
<br /> 0, ^6 % re 'R Govt.Lot
<br /> City,State 111 Zip Code Phone Number 3
<br /> 1 NW'/, �k/ %,, Section O
<br /> e /-esi t:J.. - 5-,, t2 (circle one)
<br /> II.Type of uilding(check all that apply) Lot# T N R E or W
<br /> 4:1-or 2 Family Dwelling—Number of Bedrooms X / ( Subdivision Name
<br /> Block# +rrr(7/p7 aiq./yt,?/S
<br /> ❑Public/Commercial—Describe Use
<br /> ❑City of
<br /> 0 State Owned—Describe Use CSM Number ❑Village of
<br /> AUG 0 6 2015 gown of 3r i s f--,e,
<br /> III.Type of Permit: (Check only one B allarNkattI B om lete line B if applicable)
<br /> A. 1nvlr011 lienta�lelaitit
<br /> s New 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 ❑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 /> 4,n . o, /.-b0 /5/a L) 3.)” 93, 31 . s`
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units a, [
<br /> U
<br /> v
<br /> y 2
<br /> New Tanks Existing Tanks
<br /> _ H
<br /> Septic or olding Tank I dye, ?deb, 1 ,Y'e-,,c Je ---E
<br /> Bo g Chamber 8 0 0 8 f e e-
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plumber's•5`;,rag, / MP/MPRS Number ,
<br /> STEVEN R. CROSBY
<br /> 227009 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 /> proved ❑ Disapproved Permit Fee Date ssu., Iss _ - - _ .� //
<br /> 1 $
<br /> ❑Owner Given Reason for Denial �'31.— g' '/ g� � _'
<br /> IX.Conditions of Approval/Reasons for Disapproval r
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 e It Inches In size
<br /> SBD-6398(R. I l/i t)
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