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■ <br /> rAtr. \ <br /> '\l' County ••� <br /> /gA_ .; Safety and Buildings Division 4iV e <br /> Is(4r314- ,.,, l): 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> , Madison,WI 53707-7162 <br /> ' �� I3- 20 tC-Odaa <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),Stets. �r--' <br /> I. Application Information—Please Print All Information 7 e-W e,e \J <br /> Property Owner's Name Parcel# <br /> 1(e•1rt ,I 43 chi e_/ Li t n 7) . k/ 0511-242- .choDt7 - i <br /> Property Owner's Mailing Address Property Location <br /> es0f i> Q e— - r Govt.Lot <br /> City,State Zip Code Phone Number of-K,' g4 Simon �` <br /> C )4dg h71-p 15- 3-8/ T V N; R (t ) <br /> IL Type of Building(check all that apply) Lot 8 W <br /> `%■ t of 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> q59, own of v„.. <br /> V/J t-K <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Onl y <br /> ti Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber I ❑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 /> gl,..N <br /> on-Pressurized In-Ground ❑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 Fl w(gpd) Design Soil Applicotion f) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> YkSZ Pt // 5 I !`ate 191 s r 95-, , <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks 13 1 i i <br /> F. <br /> l k U Al A u.C7 <br /> Septic gTank l l� / 4e/t47- <br /> Dosing Chamber <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installs•on of the POWTS shown on the attached piano <br /> Plumber's Name(Print) PI . . •' MP/MPRS Number <br /> STEVEN R CROSBY / 227009 <br /> ,/ / wf/41ft, 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 P i Fee Date Issued Issuing tSi <br /> ❑Owner Given Reason fix Denial $ <br /> t/9/ -r p-(72cYs- ? " <br /> IX.Conditions of ApprovaVReasons for Disapproval p <br /> P"iiW r ti ; Cz) 6 x_4sef GE�J (f243 -f'QS , <br /> REf6qt< serer- CLO 6f74- ((r7( cfaf ((28 " , F1) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In a I I Inches In size <br /> SBD-6398(R. t l/1 l) <br /> I <br /> I <br />