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<br /> ,'QE. t_` County
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<br /> A • • 9 4 i I Safety and Buildings Division Oct ne
<br /> )$ . . ' 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)- '1 P , I '�� Madison,WI 53707-7162 _ �` J - , - ,
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<br /> , ,..,„,us,.....v Sanitary Permit Application State Transaction Number
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<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.o r e T s ttted to I Project Address(if different than mailing address)
<br /> the Department of Safety and Professional Servies. Personal informal' rid btb se ndary
<br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.
<br /> I. Application Information—Please Print All Information �� �.0 t I l�1i,l.q h by r2 d'
<br /> Property Owner's Name Parcel# J ,
<br /> wart 60 ✓rtczr= Public Health MDC eNo1 /G 3- et-No - v
<br /> Property Owner's Mailing Address Environmental Health Property Location
<br /> : 35— W •3 Q /'), S t 1 Govt.Lot �`\ha 1
<br /> City,State Zip Code Phone Number >-" 11 , 6• �j /a, h, 5eEorW
<br /> ,2t t el n ectpo )t`, ty
<br /> _.5‘,X. 1(:)(-1 T (circle one)
<br /> H.Type of Buil ing(check all that apply) Lot# N; R Cr E or W
<br /> IE,' I or 2 Family Dwelling—Number of Bedrooms L/ / Subdivision Name
<br /> Block 8
<br /> 2 Public/Commercial—Describe Use
<br /> ❑City of
<br /> Li State Owned—Describe Use CSC[Number ❑ Village of L
<br /> i �l ,1 c v (A Town of Wl u,•ti}erf U% e
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' I R.New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only O.Other Modification to Existing System(explain) I
<br /> I 1 B. l ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
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<br /> Before Expiration I Owner
<br /> N.Type of POWTS System/Component/Device: (Check all that apply)
<br /> u Non-Pressurized In-Ground ❑ Pressurized[n-Ground a 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) I Design Soil Application Rate(gpdsf) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) I System Elevation
<br /> VI.Tank Info i Capacity in I Total #of i Manufacturer
<br /> Gallons Gallons Units I o'g , u
<br /> New Tanks ; Existing Tanks u o u = i — 2
<br /> j c. U . Ent, 1 ;n ( u.t7 a
<br /> Septic or Holding Conk t O S U
<br /> ■!G U / Mid .A Ae, i +
<br /> Dosing Chamber C/�,, G oO f ,r`l c�L ll`l /'4 :‘,
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<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 Sig re MP/MPRS Number
<br /> STEVEN R. CROSBY < _ 227009 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code) —�
<br /> 7361 DARL[N DRIVE, DANE, WI 53529
<br /> VIII.County/Department Use Only
<br /> i Permit Fee Date Issued �IssGing Signature
<br /> Approved ❑ Disapproved S a� Q /
<br /> 1 ❑ Owner Given Reason for Denial t, c:1'b ' , 824
<br /> IX.Conditions of Approval/Reasons for Disapproval
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<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tiz e 11 inches in size
<br /> SBD-6398(R. I VI 1)
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