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,---- ;;}� R C E I V E County <br /> r°., ty-and Buildings Division (//��`e <br /> if 4 .,' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,. S Pi ��� 4 . AUG 0 3 2016 Madison,WI 53707-7162 <br /> ‘\';'i,-,--.._-• �- /1—, C1 O° -3a <br /> N..ft+„l,,,_20.i Public Health MDC <br /> Sanitary rermit"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(1)(m),Stats. , <br /> I. Application Information-Please Print All Information 1.,4 c 0r,v.B <br /> Property Owner's Name / Parcel# <br /> u O h vi d` ..1/47.0-#1e+ (,t>t , e.' Y'vp^1� e g 66 a2/-3— q`3 3 U --6 ./ <br /> Property Owner's Mailing Address (n1 Property Location <br /> q`( Ct I 9Dl•4vte .i�4- Y/ttye- Govt.Lot <br /> City,State Zip Code Phone Number S Li 1/4, 5k.: %, Section A. / <br /> S4u) - et tUZ 535£f3 (circle one) <br /> T q N; R to EorW <br /> II.Type of Buildingcheck all that apply) Lot# <br /> A 1 or 2 Family Dwelling-Number of Bedrooms '3 t Subdivision Name <br /> Block# —❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> _ ®Town of mtt'Zprkt ell,e <br /> CV/ 16 <br /> III.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 rol 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 /> (8'Non-Pressurized In-Grounds ❑ 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 <br /> `LW t Cto0 q00 Q ?,0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units JD ° o u 'g E <br /> New Tanks Existing Tanks u ' Y . g 1 <br /> a U .(7,. e7, <br /> wO n. <br /> Septic or Holding Tank /JO / / d / M f a!X.-t a <br /> Dosing Chamber 6'6 Li ,, &00 _ <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 /> Plumber's Address(Street,City,State,Zip Code) `..- <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> �I.County/Department Use Only <br /> Permit Fee I Date Issued Issuing A ignatu e <br /> Approved ❑ Disapproved $ / <br /> ❑ Owner Given Reason for Denial �'140K 11 f'r <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 5 I t inches in size <br /> SBD-6398(R. 1 1/I 1) SC 4 NED <br />