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' `0a'rllF�•. <br /> County <br /> Yk' `'` ��� Safety and Buildings Division � � <br /> /; Sp 1-1 201 W.Washington Ave., P.O. Box 7162 <br /> \.� $ i ; Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,,�k, , 13-201-a03 1 <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(I)(m),Stats. <br /> I. Application Information—Please Print All Information , t <br /> Property Owner's Name r� ) " 2 <br /> 6 g 2 l<r n2 L L Parcel# <br /> Property Owner's ailing Address d a8 7 3°- -8 8/p - D <br /> N <br /> �/p J60N4) l2 B S e C 14 `> t/ Property Location <br /> / ' d �/l /3 bx d y9 i,4 <br /> City,State <br /> Zip Code Govt.Lot P Phone Number <br /> ' 24 AL i.�'g cri Af/� ,Y 3 7 y S/ /UGrS %, /(I ti/ /,, Section 3� <br /> H.Type of Building(check all that apply) Lot# T (circle one) <br /> N; R -7 EorW <br /> ` Tor 2 Family Dwelling—Number of Bedrooms y ) Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> i 911 b F2rTown of 11J9/7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> ' <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List <br /> Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply <br /> ❑Non-Pressurized In-Ground ❑ Pressurized hi-Ground ❑At-Grade' 4 tclound> ' , • , ,• - • L <br /> — • rN[ound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) <br /> . 0 Pretreatment ► v{ze,(eyplaa} <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> lo/.1 V,1,. !�` <br /> VI.Tank Info Capacity in / Total / #of© �� er 7 '' <br /> Gallons [v[anufactt�rer <br /> Gallons Units o ' <br /> New Tanks Existing Tanks ' g Cj <br /> a`U r2 g g <br /> Septic or Holding Tank , $ 07 w 0 G. <br /> Dosing Chamber d f9(4 I 11/1‹�st e bLs- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installati,• of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's,Si t•f <br /> STEVEN R. CROSBY MP/MPRS Number <br /> 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 ❑ Disapproved Permit Fee Date Issued Issuing A Signature <br /> ❑Owner Given Reason for Denial $V��(Q, I �!- '/5- <br /> IX.Conditions of Approval/Reasons X, 4 3d �-- <br /> pp l/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x II inches in size <br /> SBD-6398/R I I/1 I) <br />