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r ,"\A f.arv�o�, County
<br /> /5';')I•' �_ °� Safety and Buildings Division R,
<br /> y 3
<br /> t1 S Im / 1 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> .. . PS, �? Madison,WI 53707-7162
<br /> Frsrc,,,,-s' ICE C E I V E a State Transaction Number
<br /> Sanitary Permit Applicatio
<br /> to accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the approp M ettrlyptiptal unit
<br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTcare su'liYnitted to Project Address(if different than mailing address)
<br /> the Department of Safety and Professional Servies. Personal information you provid be used for secondary
<br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Fuorc Health MDC
<br /> I. Application Information—Please Print All Information argil onmt;fttal Health
<br /> Pro erty Owner's Name Parcel#
<br /> pa Illd t--- /4--filgt; t, ,),,,,I Y A 6tat Cr, z,'6,-1, - ,Z3C, c I--5-.60- 4
<br /> Property Owner's Mailing Address Property Location
<br /> / /&6,
<br /> /�Cv �✓ (/ t - Govt.Lot
<br /> City,State ` Zip Code
<br /> Phone Number N lJ /, S /
<br /> , Section bC' r>111( r r W)-' S3,3---3 j (ctrc .n e)
<br /> II.Type of Building(check all that apply) Lot# T N; R I q1 W
<br /> 01 or 2 Family Dwelling— b f / � Subdivision Name
<br /> �f:-,A,v 49 IV it Block#
<br /> ❑Public/Commercial—Describe Use •
<br /> JUL 0 7 2016 D City of
<br /> El State Owned—Describe Use CSty[Number ❑ Village of
<br /> Public Health MDC Town of C.J7t;._s II,'4"IS
<br /> Environmental Health
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A.
<br /> Ztl 'ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only i:j 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 /> N.Type of POWTS System/Component/Device: (Check all that apply)
<br /> Ion-Pressurized In-Ground ❑ Pressurized In-Ground El At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
<br /> olding 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(st) Dispersal Area Proposed(sf) System Elevation
<br /> 1,5-- L>, 31S 39b. 9e,5 -
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units o a o
<br /> New Tanks Existing Tanks i y a ' -
<br /> aU i Co at7 o
<br /> Septic or-ffntt}ing Tank /`0 r 2) i J1S-vr ',1 7e 4 g)C IL
<br /> Dosing Chamber ` o (64v>(6D /
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> ,
<br /> Plumber's Name(Print) Plumb I.nature__ MP/MPRS Number
<br /> STEVEN R. CROSBY ��" 1 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 /> Approved Cl Disapproved Permit Fee r7Date Issued ( Issuing ant Si ature
<br /> ❑ Owner Given Reason for Denial $ 7_.s---.9,04.
<br /> C 71-e4447—
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> CeHKH((ea' 'RAMj 047/fr' /ry F4 /1\ J(-{qy -- f(? F-0/4_
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I t inches in size
<br /> SBD-6398(R. 1 I/11)
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