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i ,.\.4)?.. T\f �.�\ County <br /> 4"%''''' <br /> '�'% : ��� Safety and Buildings Division 6,nre <br /> 1:f' � 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> i r� ' �.r Madison,WI 53707-7182 <br /> 1;YYI(gc),/ <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 <br /> Property Owner's Name Parcel# <br /> /4bbe ' RD S4-- Z,(r $- aSy--0042 - a <br /> Property Owner's M ling Address Property Location <br /> 749 1r /aft / Govt.Lot <br /> City,State Zip Code Phone Number /f& ,/4 <br /> r ��/., Section <br /> 41( S-'- &r_ 7 f ' circle one) <br /> II.Type of Building(check all that apply) Lot# T p N; R E or W <br /> lor2Family Dwelling—Number of Bedrooms 42 d Subdivisio Name <br /> Block# 4 r` ,(G(b.0 3 ) ice) <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of /� <br /> ❑Town of r It <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. k!,New System ❑ Replacement System ❑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 /> on-Pressurized In-Ground ❑Pressurized h1-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 Application Rate(gpdsf) ' Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 1 0 a 7 /074- 1, O?) 88 tT r,(I '84 ,8' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o R g <br /> New Tanks Existing Tanks t g N g ft i <br /> $V in . 0 4.v F. <br /> Septic or Holding Tank p eTe ! �4Qr <br /> Dosing Chamber • Ie.'P 9 /C/ I ((�/LCD fCC <br /> -V- <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu hilt MP/MPRS Number <br /> STEVEN R. CROSBY 227009 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 0 Disapproved Pe it Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ 1. <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1121 I I Inches In size <br /> SBD-6398(R. t t/l i) <br />