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:_,9..—Kri,c'r•. County A <br /> ,i'r,A ,. Safety and Buildings Division <br /> zr::0 201 W.Washington Ave., P.O. Box 7162 taU„ <br /> $ Sanitary Permit Number(to be filled in by Co.) <br /> y FS �`i Madison,WI 53707-7162 f <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(l)(m),Stats. <br /> I. Application Information-Please Print All Informatiorf �E 1V ED �0 �-J,t,, Rd Property Owner's Name (� 1 Parcel# <br /> J a ni(IS a ke/t 4. 14NdP.-' e.^Q MAR VI 2016 O-71.2 - 3AV - 9 LI 3o - 0 <br /> Property Owner's Mailing Address l Property Location <br /> L U t e cv Public Health MDC <br /> l�� Pctfk <br /> City,State �� Zip Code Elwiro rl, Ibt ealth Govt.Lot <br /> / S (A) `�+, 5 e '/, Section 3 2 <br /> Oecam.^tr e /6.9 L.)i 3- 35- 3 i (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T 7 N; R % EorW <br /> t® I or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> a Town of De's~ eId <br /> /`// .>G <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> Q New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ril 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[sued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) , <br /> El Non-Pressurized[n-Ground Cl Pressurized[n-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(sf) Dispersal Area Proposed(sf) System Elevation <br /> L-I .5.0 , q 112.6 11,z V _ qc.5 _ its <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o y o <br /> New Tanks Existing Tanks e u a y u` •13 o a U h cir w U 0- <br /> Septic or-Wilding Tank /000 <br /> 4.-..... /000 / 1)?f'at' -( 14 <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si: .. e ._.. MP/MPRS Number <br /> STEVEN R. CROSBY .-'` ! . 227009 <br /> 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 /> 4pproved ❑ Disapproved Permit Fee Date Issued [ssuin Agg t Si ture <br /> CI Owner Owner Given Reason for Denial qO '''''''m"- <br /> 748'21 6 i\tot/te <br /> C <br /> IX.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 1/2 x I I inches in size <br /> SBD-6398(R. 11/11) <br />