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,$,/ '\\� �[ County
<br /> e l' �. q 519 Safety and Buildings Division ?�Q,.��
<br /> if $ 'i` :` '7:1,, a 201 W.Washington Ave., P.O.Box 7162 Sanitary permit Number(to be filled in by Co.)
<br /> ''l <=_!; ` /// t Madison,WI 53707-7182
<br /> %" ( 3-2t�t.G- 10291
<br /> Sanitary Permit Application State Transaction Number
<br /> En accordance with SPS 383.21(2),Wis.Aden Code,submission of this from to the appropriate governmental unit
<br /> is required prior to obtaining a sanitary permit: Note:Applicati 1 W, !, , .1 submit to prod Address(if different than mailing address)
<br /> the Department of Safe and Professional Servies. Personal in 't,: ) ,u u r secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1 Xm),S k. t ,
<br /> I. Application Information—Please Print All Information d -� er l yq& 4�
<br /> Pro Owner's Name
<br /> �," Parcel#
<br /> s a l l p e n e l/
<br /> Pula*:H.Rlrn etnr D 9!l 3c5.3 -a�k ö 0
<br /> Property Owner's Mailing Address j Environmental Health Property
<br /> 3�z,y El1-� 'R� l�eation
<br /> Govt.Lot
<br /> Ci State n Zip Code Phone Number
<br /> De ,('' '-)--• te, - S-3—.1— =1,
<br /> -i� 4/ %,, S %., Section
<br /> IL Type of Building(check all that apply) Lot# T N; R 1/ W
<br /> or 2 Family Dwelling—Number of Bedrooms j b Subdivision Name
<br /> vv Block# I--i`S 4-61 ( ?4 f 4 „
<br /> ❑Public/Commercial—Describe Use
<br /> ❑City of
<br /> ❑State Owned—Describe Use CSM Number ,,❑{{Village of
<br /> 1t"own of 0 1-134 c I
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A4;Frew System 0 laceme t System ystem ❑Treatment/Holding Tank Replacement Only 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 /> wed. ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil AMound<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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed posed(s0 System Elevation
<br /> ban 0.4. S2.t,) lovD ( /.OIL 11■70.- C deb) /a/.e9
<br /> VL Tank Info Capacity in Total if of Manufacturer
<br /> Gallons Gallons Units
<br /> New Tanks Existing Tanks S E 8 i V y
<br /> Septic Ott Tank _ U rn a y w C7 0.
<br /> Dosing Chamber 1 a �� -- J/2-cg4, ` Al V- f
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plumb .";' 7---_ MP/MPRS Number ,
<br /> STEVEN R CROSBY ....•• /(101—+ 227009
<br /> 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7361 DARLIN DRIVE,DANE, WI 53529
<br /> tVIIII.County/Department Use Only
<br /> w Approved ❑ Disapproved Permit Fee Date Issued Lssuing Agitat S'0.1 El Owner Given Reason for Denial $12 � ��20/ C 24-0144.----
<br /> IX, ditions of Approval/Reasons for Disapproval
<br /> xo-7Ec i Auboo Jtr7E,a, e AQCSA is ©a!✓�► .�, >tt; cp c t
<br /> *4c -144 4 o Pfx&L i 7.A499., c
<br /> --P OFf—LoT Adil c"OtvT 044k.tPT 8 - 4 ,o 4✓✓O R'344.6o /°.21alt. Ta
<br /> I$ A, o civo ,ect.CTe// .7, ,4-4,44, AiolA∎to /t/V' LaEf'Ilfwira o vaor,,* 'z ye-6
<br /> Attach to complete plans for the system and submit is the County only en paper not less than a In x t t inches in size
<br /> SBD-6398(R. I l/1 l)
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