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•tro.ar1 County <br /> //.4.' I IN Safety and Buildings Division O U n e— 3F1 <br /> (-47 S �, <br /> s\ "1 <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> p <br /> Sanitary Permit Application State Transaction Number <br /> In 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 i rt 4o) E*Po r' -Peg, I <br /> Property Owner's Name t h C Parcel# <br /> v ` <br /> Property Owner's Mailing Addres- _ . • Property Location - <br /> / l>0 5 L •ii I-- Cr(i-e `1,C)7 °A‘( ,4k�J(4 Or�4�-4 Govt.Lot <br /> City,State t/ Zi e> Phone Number �, , <br /> Ai E /,, /I,E %, Section / <br /> . 4 I/ /+ (circle one) <br /> II.Type of Building(check all that apply) Lot N T N; Ft_ // E or W <br /> g 1 or 2 Family Dwelling-Number of Bedrooms L-7\) i/ ^6 5ubdirision Name <br /> Block+k Orur„l 1., l n,fee1< <br /> El Public/Commercial-Describe Use <br /> El City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of L <br /> g Town of art"t s I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 4New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal CI 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 En-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(gpdj Design Soil pplication Rate(gpdsf) Dispersal ea Required(sf) Dispersal Area Proposed(sf) S2 m-Elevation <br /> 6 6 D d z L/ /5-0 0 /SoO 26-q /C,-.5-- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o u <br /> New Tanks Existing Tanks e u o f t <br /> a` U iii vi w C7 o. <br /> Septic or Holding Tank /02?e, 12 n / /)'E �, �, <br /> Dosing Chamber c o U OU / gip d- <br /> VII.Responsibility Statement- ,9 <br /> ent- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) • Plumber's Signature MP/MPRS Number <br /> STEVEN R. CROSBY _ 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> i <br /> VIII.County/Department Use Only <br /> .-' Permi Fee Date Issued Issuin Agent-Signat�tre <br /> \x,,,,,'r Approved ❑ Disapproved o_ /// <br /> ❑ Owner Given Reason for Denial - 1 •e x1427 /�J 4 Pa:�- <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 g 1/2 x it inches in size <br /> SBD-6398(R. 11/11) <br />