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isr-,0 Safety and Buildings Division County <br /> ,g'-' <br /> r, citi 201 W.Washington Ave., P.O. Box 7162 <br /> •': , <br /> Sanitary Permit Number(to be tilled in by Co.) <br /> .: il.II S p 1"--) 417‘i <br /> Madison,WI 53707-7162 <br /> i(,- 000 i <br /> Sanitary Permit ApplicationNrYi '.r;1 ,-,.. State Transaction Number <br /> ,.. , r <br /> En accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate goVertmte 'f 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 0 Leki-ci i iic <br /> Property Owner's Name A RECEIVED Parcel# <br /> /IA 71/ Cites 1.01." <br /> ? 7&) --0 <br /> _ <br /> Property Owner's Mailing Address <br /> APR 2 0 2016 Property Location <br /> I 3 ' ..-/-1))/-00/A , /2 Govt.Lot <br /> City,State Zip Code 11■118fid-Noltibtmoc <br /> N.)k.. 1/4, /1/ - 1/4, Section .7Q <br /> Ermironmental Health <br /> ),0 "L Z•e....) ,S-.7 7e). , (circle one) <br /> T d N; R (, E or W <br /> II.Type of Building(check all that apply) Lot# <br /> VaLLor--24amily Dwelling-Number of Bedrooms 3 / Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> -Town of (P/ze e k. c, 4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only r,1 Other Modification to Existing System(explain) <br /> ..: _ <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground ' 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> V,) d 07 co 7 15-0 8e7O <br /> 49 1 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 41 t '0 c.) <br /> .4) 11 <br /> New Tanks Existing Tanks <br /> a. u . :: c <br /> B A a <br /> v) 1 a. <br /> Septic or got/ling Tank i 4957 --- /n,2), f igeafrie ` t.'' <br /> Dosing Chamber <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 MP/MPRS Number <br /> STEVEN R. CROSBY r 227009 608-849-8771 <br /> ■ <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 t Si ate <br /> Al-Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial i i4- LI.-2.4...-zot‘ <br /> c <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ---) eg9-rEr--7' r- 474t, #1,‹A 45— FEE--7 PoGvi/razyCt-- <br /> FA-3'■ -Cog C-9/49*---6-Vee P'11.- 6-71-crtVit* e ,4AJa Mkitailvg- VAKPC, <br /> r , <br /> ---", 11,4 I( r il sz_ ( r 1.. -rj doitti- of- 1-1,3‘.el 4 tit,, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 t t I inches in size <br /> SBD-6398(R. 11/1 I) <br />