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County r <br /> * `4 , Safety and Buildings Division Dane <br /> ft '��t s #� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be Felled in by Co.) <br /> '°� �S`p;:" ) Madison,Wi 53707-7162 <br /> •. �irss�l / ' <br /> ':;.4'4!.. 3-2d/5---cizgc <br /> . <br /> Sanitary Permit Application Stale Transaction Number <br /> to accordance with SPS 383.21(2),Wis.Adm.Code,submission of Ibis that to the appropriate governmental unit <br /> is requited prior to obtainiog a sanitary permit.Note:Application Feints for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servit s. Personal bilbamtlon you provide may be used for secondary <br /> purposes in accordance with dire Privacy Law,s 15.44(I)Sri. E C E I V E D 4540 American Way <br /> I. Application Information—Please Print All Infortaa <br /> Property Owner's Name Parcel I <br /> Mark Taylor,John Shivick JUL 2 7 205 0711-0346166-2 <br /> Property Owner's Mailing Address Property Location <br /> 2199 Liberty Road Public Health MDC Govt.Lot <br /> City,State Zip Code EnvirontrfetatbllnHealth SE ;s, SE sr.,section 3 <br /> Cottage Grove,WI 53527 „ (cirek one) <br /> T 7 �; R 11 <br /> U.Type of Building(check all that apply) Lot I <br /> ®I or2 Family Dwelling—Number of Bedrooms 3 16 Subdivision Name <br /> Block# American Heritage <br /> 0 Public/Commercial—Describe Use 0 City of <br /> 0 State Owned Describe Use i ivS Number 0 Village of <br /> ®Town of Cottage Grove <br /> III.Type of Permit: (Check only one box on line A. Complete line 13 If applicable) <br /> A- O.New System Y..Replacement System griPresratesetkddlItnanlrlteIRSeellarareirly 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous/Permit Numbermrd Date Issued <br /> Before Expiration Owner 2 6Ct Big 7S3 i Z—7-I e , <br /> Iv.Type of POWTS System/Component/Devieer (Check all that apply) (( <br /> ®Non-Pttssurized le-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required 40 Dispersal Area Proposed(sl) System Elevation <br /> 450 0.58 774 774 Existing —100.0' <br /> VI.Tank Info Capacity in Total ft of . Manufacturer <br /> Gallons Gallons Ikons B 4, <br /> New Tanks Exfttias Tacks C>= g 't 'I A e :8 <br /> a d 'v1 K a r=rd i% <br /> Septic er taYingTmk 1000 — 1000 1 Crest x <br /> Dosing Chamber 600 600 1 Crest x <br /> Vit.Responsibility Statement 1,the undersigned,assume wdbility for installation of the POWTS shown on the attacked plans. <br /> Plarber's Name(Print) Number's lure hIP/MPRS Number Business Phone Number <br /> i -o(s<PA- 41---D,,,,,,„k_. 717,1_ (cot' .x'73 /C1 <br /> Plumber's Address(Strad,City,State.Zip Code) <br /> i ” 0 Gt r? e at 14 a�� .r W� C' 1'"�f• <br /> VIII.Couaty/Department Use Drily __✓✓ <br /> jgApproved 0OwnerGive 3I( ate- 11+D 2D(S—cC �VIYf� <br /> ❑Owner aver Reason for Denial 1 <br /> IX.Conditions of Approval/Reasons for prow Q./ ^/G— 1O�J• 0 L rf Ri hie <br /> - A/4!✓ fl° [7� T ' '[ <br /> -A/YK ID 8E ieofa y 4.49)4 tyri o.KE-10lAck cE�GI <br /> ' Ica /26 -� -o t,-.C1sT/4&'.1RA+ �be � '(O � r14,7weF, <br /> mtach to complete pious for the semen meet submit to tee C emty oe paper set lax than l 12 s I1 inches In size <br /> SBD-6398(It.1 1/11) <br />