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__..4-.,f/ CJ I 1/ , :-� I 1 (-) t 3(r-t)1/G%I r/ O "�t.. c 1 O C„,ts.�Cl!" / <br /> 'vt�,�arir`A,;• / 1 ( ! r— County j� <br /> °`; ci Safety and Buildings Division %A lr-=' <br /> jX; ;0 S 5- 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '� O� Madison,WI 53707-7162 <br /> S° I / <br /> _,:, /,3 <br /> Sanitary Permit Application State Transaction Number <br /> [n 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(l)(m),Stats. l - <br /> L Application Information-Please Print All Information RECEIVED 'a` -�i,v <br /> Property ner's Name Parcel# <br /> '�/ L. l e et, /k C At1G 1 6 2016 © e 2 7-6//- f 70 - c'", <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC i.--'"�'A, 1 <br /> ��.1> Q' ,� 77-74�'� Govt..Lot <br /> City,State / Zip Code Er P11one r7umbera) Health r J <br /> / Z /<, /:, Section <br /> di( 7'L`,r‘. 7i r,G, N; R (circle ore) <br /> II.Type of Building(check all that a�ply Lot# <br /> Fl or 2 Family Dwelling-Number of Bedroo s y c Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use 7 Number ❑ Village of <br /> own o !' 'it It <br /> 13,a <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. -New System ❑ Replacement System TreatmenHldin Tanc-Re lacem enLL t Onl y <br /> `"�. Other Modification to Existing System(explain)`-- <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pe it Number and Date Issued I 470 <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (C)l trek til-.that,@pply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized[n-Groul)tl' itri At-Grade \❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(expl in) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Applicationn(Rate(gpdsf) Dispersal Area,Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o 11 v <br /> New Tanks Existing Tanks e u y <br /> aU ti H rn u. (..7 a. <br /> Septic or Holding Tank _. __ <br /> Dosing Chamber ` ! / I 6 ..cc ( G t <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-S'""°atu / MP/MPRS Number <br /> STEVEN R. CROSBY ( 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 /> � <br /> Approved ❑ Disapproved Permit Fee Date[sued lssui Agent Signature _____.*K-.,, <br /> $ -/ <br /> ❑ Owner Given Reason for Denial rj / " <br /> Conditions of Approval/Reasons for Disapproval, t' °` ' - <br /> T 1 /+,tv ( S. : ( 3 / 4& /L t'° <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x t 1 inches in size <br /> SCANNED <br /> SBD-6398(R. I l/1 l) <br />