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'\ County <br /> !" \ 04 Safety and Buildings Division �, y <br /> J I 201 W.Washington Ave., P.O.Box 7162 r o ) <br /> y r/ J.r ! Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,N,p -- 4`1 :fir- -`--(,,,/1-.. ./ <br /> ``r. j,...)r..t <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 "� r) <br /> Property Owner's Name U U /Q <br /> Parcel# <br /> Pro erty Owner's Mailing Address b O S._ 3 3 " 76,e, 1 " O <br /> 7 r a rwc z /� , j Property Location <br /> City,State L. -7(' t Zip Code Phone Number Govt.Lot <br /> H.Type of Building(check all that apply) \ Lot# T N; R e, W I <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms / y Subdivision Name <br /> ` ____ 'J Block 4 !L> /LC 0'2_2_r <br /> 2 Z r -- <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> CI State Owned-Describe Use CS M Number 0 Village of r <br /> C_Town of sp' s° <br /> I` f7—i fee 12 <br /> III.Type of Permit: (Check only one box on line A. Compl=te line B if applicable) r f <br /> A. <br /> kNew System ❑ Replacement System ❑ Treatme t/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. CI Permit Renewal CI Permit Revision ❑ Change„f Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 1 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all hat apply) <br /> -Mon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-G ade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Disper al Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> / 7 J l6 T 7g- >9.s 6v, S---- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons allons Units y o <br /> New Tanks Existing Tanks ;� E U <br /> V H g g <br /> 8,7 U y y o7 ii 0 a <br /> Septic or Holding Tank I ,577 / <br /> Dosing Chamber /����_ <br /> VII.Responsibility Statement- 1,the undersigned,assume respo eibility for ins Lion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb re MP/MPRS Number <br /> STEVEN R. CROSBY ''-' 227009 <br /> '� �& 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 /> Approved ❑ Disapproved Pe tt Fee Date Issued tssuin nt Signature /// <br /> `~ G✓1� <br /> ❑ Owner Given Reason for Denial <br /> ° g l_ 1 i /f 'C / <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and sub,it to the County only on paper not less than 8 to e l I inches in size <br /> SBD-6398(R. t l/l l) <br />