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, . <br /> County <br /> , Safety and Buildings Division 0 on e <br /> (4' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> '', Sp )-1 ''- ',.:, ' Madison,WI 53707-7162 <br /> \-1.?,., " — — 000 7-S- <br /> \ <br /> Sanitary Permit Application State Transaction Number <br /> [n 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),Stats. <br /> I. Application Information-Please Print All Information RECEIVED Parcel# /fcl _ <br /> Property Owner's Name ./ <br /> 60(0'f— 0 <br /> ., <br /> _..,--•, _,,, k <br /> i ,ryt 0 f 4 9 Mtv,.1-,el IA- <br /> 5c (A.),ji tam von APR 1 f 7016 a Yo R-- - <br /> Property Owner's ailing Address Property Location <br /> gi.+2 CI Mai'i 01 e.., Or,t/e._ Public Health MDC <br /> Govt.Lot <br /> City,State Zip Code kujtogrntal Hcolth <br /> nic-- 'A, 5 6 v., Section sc , <br /> odiec6-7 1A, T 5-35-6 -x (circle one) <br /> T V N; R V E or W <br /> II.Type of Building(check all that apply) Lot', <br /> El i or 2 Family Dwelling-Number of Bedrooms 5 • Subdivision Name <br /> Block# c), e0 Pt 69 <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> g Town of $e i"Iny d e teO <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' kit New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0.Other Modification to Existing System(explain) <br /> ... _ <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 /> g Non-Pressurized In-Ground 0 Pressurized[n-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 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(st) System Elevation <br /> '"7 yo i ../ /? 7.r 2 -0P--77 — q5- -- <br /> .5- ct -No , <br /> _.. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> u <br /> Gallons Gallons Units 1 6) o "cs 0 <br /> 13 0 t '- .n Li <br /> New Tanks Existing Tanks ti 2 a 1 A g 2 <br /> 8::0 iii iii co *CZ F.5 E.: <br /> Septic or Holding Tank 'l V 4 0 ) 1 4 a e r.a r* K <br /> Dosing Chamber . /e"'" L6e=t--t-) i ii0,0,40, A , <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! ign ture MP/MPRS Number <br /> STEVEN R. CROSBY 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 /> Permit Fee Date Issued Issuing A:el *gnature <br /> "Approved 0 Disapproved $ h....9i .A.....r <br /> 0 Owner Given Reason for Denial 7 i .00 41,17.70'4 ..4..." <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 I/2 x ll inches in size <br /> SBD-6398(R. I I/11) <br />