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`,i Al11%; \ County ) <br /> / s•-,- <br /> ,: \"f\ Safety and Buildings Division 04./e <br /> �i!�'4 $ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> . P Madison,WI 53707-7162 <br /> `r S lyr <br /> - i3- 2. 010- ©0115 <br /> \anm <br /> San' 0 ;,: I . ;1 rah I Cation State Transaction Number <br /> In accordance with SPS 383,21(2), rr . ..�,s . ission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fo for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Profes r^PErS too tqp�ou rovide may be used for secondary fj/� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats {.(E I V E D "I�(j')� � t . �� <br /> I. Application Information-Please Print All Informati `` j / <br /> Property Owner's Name Parcel# <br /> MAY 13 Y016 <br /> Sp 1, c. llla id_ht.r , 0171 -1 ba clibo—t <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> 10 -C- '' <br /> v .�Lr d Environmental Health g� �r Govt.Lot <br /> City,State Zip Code Phone Number 64;14, //,/ /, Section 1 f <br /> D r IPA/ ,•l 7,`— cir e) <br /> W L T 5 N; R I t� W <br /> II.Type ofuilding(check all that apply) j Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms yf f Subdivision Name <br /> (( Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Li/e).34, .,r--49 Town of Pu2/4s r <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only T Other Modification to Existing System(explain) <br /> ,..New <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber <br /> Before Expiration Owner <br /> I <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-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 Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> (p0 v 6 , (p lv ...,6> 104. 411:$1- - /t2$?-tr=. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A g d ,2 <br /> New Tanks Existing Tanks c 2 g 8 . 6 <br /> k U in m (r LT. c-5 a <br /> Septic or tlaidipg Tank la 8.4. ..., / /4' I *gts el.C. �'f <br /> Dosing Chamber 4 .ry .__ s pv f e/ <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 S' ... -. MP/MPRS Number <br /> STEVEN R. CROSBY de' „�, - 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 /> )4<pproved ❑ Disapproved Permit Fee Date Issued suing lit gna <br /> ❑ Owner Given Reason for Denial S �?( ---- � /s _20/6 Xe1S---. <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> ` Ri 61°00 4.1(70 Apr " <br /> m64/'r S.( - . .‘P <br /> ( 4 1* A'IGWC Co1Y.otrtp/Ir, /°/.6 7 f y48634 so/e C°iigt..�JC---7 <br /> lb"-61-(41441r.c. Atel0 1/411041.4,z_--ri-ohgr-K_. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z t t inches in size <br /> SBD-6398(R. I l/I I) <br />