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' '0 Safety and Buildings Division Paige kirivi <br /> i ID s 01 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1�5. Madison,WI 53707-7162 <br /> .9 �: t3 - plip - Cd1, ;� <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(I)(m),Stats. <br /> I. Application Information-Please Print All Information re€ c.1'? /efrace <br /> Property Owner's Name Parcel# <br /> AtoSOts) ?Al ,r 5 : LLC '''"0708 ° 3, -q - `// 7V -0 <br /> Property Owner's Mailing Address Property Location <br /> 1 301 1 er.,-e•`' ft.tr2) a,(7 Govt Lot <br /> City,State Zip Code Phone Number 5(,‘r 'A, 5�- Y., Section 3 A <br /> 60, /lain C-Al-e wely nrr $- • (circle one) <br /> II.Type of Building(check all tlAt apply) "'r . Lot# <br /> T 7 N; R iK EorW <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms t a / . Subdivision Name <br /> Block# <br /> Plea dc„..., ,r o 41s, <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of / <br /> fig Town of frrleOd/ '%L7n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only 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 /> rgl Non-Pressurized In-Ground ❑ 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 /de> -i 7SO r , '-1 18g5 .." ,/92.d �' �' <br /> VI.Tank Info Capacity in Total #of Manufacturer { }'U 44. �el•L1 <br /> Gallons Gallons Units .0 ° c v a <br /> New Tanks Existing Tanks o c u ` 4. 4 4 <br /> ac) rn �, rn w0 F. <br /> Septic or Holding Tank (o..)---b / <br /> .f 1e7�b I / fr'GGl,.• <br /> Dosing Chamber <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for[nst lation o the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's ' re MP/MPRS Number <br /> STEVEN R. CROSBY 227009 l ,-- --.�.-._ 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 0 Disapproved jPermiitt Fee Date Issued.-' Issuing Age ignature ,/� <br /> ❑ Owner Given Reason for Denial $ t o 7 c/ f/6 �� �=� <br /> IX.Conditions of A pp roval/Reasons for Disapproval <br /> a--- <br /> .r' <br /> ,..---- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x It inches in size <br /> SBD-6398(R. 11/11) <br />