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r"----7,- .eT J e . County <br /> '/ � ... \s\ % Safety and Buildings Division pane <br /> jai $ ,,:, �� 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7182 <br /> � J <br /> �1%-' 13-2(167— 003Z <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 /> purQoses in accordance with the Privacy Law,s. 1S.04(1)(m),Stets. <br /> I, Application Information—Please Print All Information (_tfl,.I }Etc,y J <br /> Property Owner's Name Parcel# —"� <br /> eeytnr5 /29rd i-171,4 el 0607- 31 - e?-70- O <br /> Property Owner's Mailing Address Property Location <br /> �. 1 3 el y-- i1,, at4Wa / gel Govt.Lot <br /> City,State Zip Code Phone Number S %4. S E. %, Section ,;Z 3 <br /> (circle one) <br /> E00415Vifie 1,t)..1 I3 . T 6 N; R 7 EorW <br /> U.Type of Building(check all that appl Lot# <br /> 'i 1 or 2 Family Dwelling—Number of Bed ms 4-/ A Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> / ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> /6 5 $� .16 Town of S�s,.+y de,/e <br /> [II.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 /> 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 /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade Meund<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) • ❑Pretreatment Device a atnj <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> (A0 o _ I4 C) 0 �) Pan- 600 //447 /•O (i ([a7r' /;15-. 7 'F <br /> VI.Tank Info opacity in Total [ #of Manufacturer <br /> Gallons Gallons Units u <br /> New Tanks Existing Tanks S rd .Y <br /> k y ez u.-F.5 0. <br /> Septic f( n o,�ieiditr /a 8,4, 1.z8 G / ,le e of <br /> DosingChamber�— ��t k ssp U 7 1 l / <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility f stallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb s•Si r MP/MPRS Number 1 <br /> STEVEN R. CROSBY ,• se _—. . 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 suing Age i attire ����� <br /> ❑Owner Given Reason for Denial _ 77/V I Z Z it �Gw" <br /> t <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> — <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x I l Inches in size <br /> SBD-6398(R. 11/t i) <br />