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,iii-i rirgyT County <br /> �' � f\ n Buildings Division Do n C �, <br /> i ( 11 ton Ave: P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> "t s ' 1 Madison,WI 53707-7162 <br /> \r S° 4' <br /> AWu B b rte-- /3- moo/b -00.2-S-4 <br /> vP it'Permit Application State Transaction Number <br /> In accordance with SPS E 383,.21 t.A.rh:a thsubmission 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(t)(m),Stats. ,�7 <br /> I. Application Information-Please Print All Information LAtr+ C r tl s5 d9r <br /> Property Owner's Name Parcel# <br /> Oaot(X Gar pt'e1 d- )<e/5 rd lt z1Pn 0710- 35 - 6 370 -o <br /> Property Owner's Mailing Address / Property Location <br /> 570't AltirAtrie 5 1. Govt.Lot <br /> City,State J Zip Code Phone Number g£ y, N it, /, Section 3 5— <br /> Ft +c Jt 6u/'q Iv r S 37// T !0 N; R 7 (circle <br /> E ore) <br /> H.Type of Buildifig(check all that apply) Lot# <br /> ELI or 2 Family Dwelling-Number of Bedrooms L/ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 1 U -Town of I3/onm*i•rq l�`dide <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. ocrsNew System ❑ Replacement System ys p y ❑Treatment/Holding Tank Replacement Only I5*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 /> (R-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.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> obt7 c0. /000 /00 8 q 7,1- 2 7.0 (It, 5 <br /> VI.Tank Info opacity in Total #of Manufacturer w <br /> Gallons Gallons Units :: o d <br /> New Tanks Existing Tanks y c u 2 2 g `g' <br /> J ] a U tom cd -iE o a. <br /> -- -Septic..4 elding-Tank—— / — `.. /.28'c / /4 ee,)..-c Pr —Dosing Chamber U ... PO / ,P Q A lael <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's ' re MP/MPRS Number 1 <br /> STEVEN R. CROSBY i 227009 608-849-8771 <br /> ,. -- (16-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 tssui Ake S t re� ��'f/t/V <br /> N-Approved ❑ Disapproved $ ��/'v° 8_Z� 2D//�D <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size <br /> SBD-6398(R. 11/1l) <br />