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' -, YARr - County <br /> /PO ki....\ Safety and Buildings Division <br /> ) <br /> ii <br /> s,' ' GI W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be Filled in by o.) <br /> 1 sps /,7 Madison,WI 53707-7162 <br /> A1 <br /> CYYn>%. <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),Slats. /�� " <br /> I. Application Information-Please Print All Information t_but/v/ %c,j/ <br /> Property Owner's Name Parcel II <br /> Pct i-t---J+c X a t- ) -' ' 0.5—//- Q/. -9///- q i <br /> Property Owner's Mailing Address Property Location <br /> e x"173 ;,IJR„ces Lar✓e <br /> Govt Lot <br /> City,State Zip Code Phone Number , , <br /> J tJ /., Nry /., Section .21 <br /> C>i y, We- L✓fX .5-y 76 / (circle one) <br /> II.Ty pi of Building(check all that apply) Lot II T N; R E or W <br /> iptl or 2 Family Dwelling-Number of Bedrooms a 07 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of i! <br /> "1 YC)'y 411 Town of 0a." if•°r.)t_ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0-New Systeny ❑ 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 Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> on-Pressurized In-Groune ❑ Pressurized in-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 /> y1`a ,7,y //t2,5 /1 9io/ 171. / ?;,9 r <br /> VI.Tank Info Capacity in Total 0 of Manufacturer <br /> Gallons Gallons Units 8 o . n C)AD <br /> New Tanks Existing Tanks u e' 2' M is <br /> a O rn t rnn 'v.0 F. <br /> Septic or Holding Tank // 16525 t XrCtieZ tt- a' <br /> Dosing Chamber 42:p / 640 - - <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum. Pr'` . .• re MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 r <br /> Plumber's Address(Street,City,State,Zip C.. <br /> 7361 DARLIN DRIVE, DANE, WI 53529 I <br /> VIII.County/Department Use Only <br /> Pern Fee Date Issued Issuing Signatu <br /> ❑Approved ❑ Disapproved <br /> ❑Owner Given Reason for Denial <br /> s 31._ z/76,A6 /) -, Y <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 a in z 11 inches in size <br /> SBD-6398(R. I l/I l) <br />