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-,i,%.,..-traanrFVr\ County <br /> /o,`3 \ n Safety and Buildings Division , �n/Lv <br /> IT( .s-----•;-,'X.I.\ RECEIVE <br /> 1..201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> i % •p„,-- -I/ Madison,WI 53707-7162 <br /> \\ ` T- ,f� AUG 2'6 2015 <br /> I3-26i5-© ��' <br /> S FF11 thk f r rte' Application State Transaction Number <br /> En accordance with SPS 383.�(1Y),fW1s. I m.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 ,. K 0 a + ,rG(k 7 a/� (71.Property Owner's Name — <br /> n 1�v1lae�; CO Parcel# <br /> (�-�-iri5 t /6 ,11.e. rV �° y- 07(.4- )gtl • aOr) 1 .. 7 <br /> Property Owner's Mailing Address t �j Property Location <br /> K;VC is (O tt.d , 6110g 1/4c,14)er Govt.Lot <br /> Ci Stay Zip Code Phone Number Al t, 1/4 N f.1 Section 1 q <br /> la 0. 4rt h Ur 53,1-&I T 7 (circle one) <br /> N; R E or W <br /> II.Type of Building(check all that apply) Lot# <br /> t r 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# 5e,L// IQ W'iti Y01 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of / <br /> 0-Town of ifiia frhA <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. b-New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only y <br /> .r 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 En-Ground ❑ Pressurized In-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 Applicatio Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> o <br /> Gallons Gallons Units u <br /> New Tanks Existing Tanks 1 c U u v <br /> 2 is <br /> ,,/ aU n , vt wv et. <br /> Septic or Holding Tank 1 D 4C. I i i[4 ( (e'/,'?.' . <br /> Dosing Chamber l as-D./, l SJ `` , <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P M ren Si', : MP/MPRS Number <br /> STEVEN R. CROSBY /� ) �� 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) // v. - - <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial S Vi7At` a-t21_I 5 n. - <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans For the system and submit to the County only on paper not less than 8 tai s t l inches in size <br /> SBD-6398(R. 11/11) <br /> 1 <br />