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i. x,2""F <br /> Sy.,.'. County <br /> `-� ''° Industry Services Division DINE <br /> x <br /> k'cf' <br /> 1400 E Washington A ve Sanitary Permit Number(robe filled in by Co.) <br /> P.O.Box 7162 <br /> i'-7, Madison,WI 53707-7162 1 201b-.W3 a t <br /> Feix)N a!i• <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. GRASSLAND TERRACE <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> CAPITOL INVESTMENTS,INC 0811-123-4177-0 <br /> Property Owner's Mailing Address Property Location <br /> 13845 BULLARD RD <br /> ' Govt.Lot <br /> City,State Zip Code Phone Number SW %,,SW Vs, Section 12 <br /> EVANSVILLE, WI , 53536 (circle one) <br /> To8N; R11EorW <br /> II. ype of Building(check all that apply) Lot# <br /> t or 2 Family Dwelling-Number of Bedrooms 175 17 Subdivision Name <br /> SAVANNAH VALLEY <br /> Block# <br /> _Public/Commercial-Describe Use <br /> City of <br /> State Owned-Describe Use CSM Number Village of <br /> 71 Town of SUN PRAIRIE <br /> III.Ty e of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement Treatment/Holding Tank Replacement Only _ Other Modification to Existing System(explain) <br /> System <br /> B. Permit Permit Revision _Change of Permit Transfer to New List Previous Permit Number and Date Issued <br /> Renewal Before Plumber Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> _ Non-Pressurized[n-Ground Pressurized ln-Ground At-Grade _ Mound>21 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 Dis sal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> a0 Rate(gpdsf) j ( 0 7- 105.2 <br /> �� 0.6 / I/ _ 1i WT' <br /> VI.Tank Info Capacity in 2 <br /> Gallons v c <br /> o <br /> Total #of u n °- <br /> Gallons Units <br /> Manufacturer <br /> New Tanks Existing Tanks U r ` <br /> 2 <br /> n., <br /> in <br /> Septic or Holding Tank 1650 1650 1 MEADE <br /> Dosing Chamber 1000 1000 1 MEADE <br /> VII.Responsibility Statement- I,the undersigned,assume res.onsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si". J MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY �/ /� ` J 227009 608 349 8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DR, DANE WI 53529 <br /> VIII.County/Department Use Only <br /> Disapproved Permit Fee Date Issued Issuin:Agent Si: •• —/ , <br /> Appro S`1��/ - , <br /> Owner Given Reason for [ (O �, <br /> /2/S, 1S <br /> Denial G- —�7 <br /> LX.Conditions of Approval/Reasons for Disapproval ._-- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 a 11 inches in size <br />