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■ <br /> County <br /> `''� ''\ Safety and Buildings Division Dane S/1l <br /> 4.1-Y!.:-4.-... IV <br /> r- I:? ', , 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(m be filled in by Co.) <br /> a -3P rl Madison,WI 53707-7162 <br /> W, S <br /> `„ & /3, /6 -Goff(. v <br /> \',`� 20 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 303.21(2),Wis.Adm.Code,submission of this loam to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note,Application forms for slotrmvned POWTS ore submitted to Project Address(if different than mailing address) <br /> the Deportment of Safety and Professional&Ivies. Personal information you provide may be used for secondary <br /> purposes in acconlance with the Privacy Lau',s.15.04(1)(m),Slots. c L \ Town Hall Road <br /> 1.Application Information-Please Print All Information J 1-^'A <br /> Property Owner's Name 'f-.- Dowel d <br /> �0607-174-8075-0 <br /> jniel&Kelsey Elver AUG 2 a 2C16 <br /> Property Owner's Mailing Address Property Locution <br /> 131 Buechner Circle prLhlliir Health WIC coy Lot <br /> City,State Ztl e EnvikfiVi l Health L.----NE v., SE 7.,(elide Section one)17 <br /> Mt.Horeb,WI 35 T 6 N; R 7 E or W <br /> Il.Type of Building(check all that apply) Lot A <br /> - <br /> ®1 or 2 Family Dwelling-.Number of Bedrooms <br /> 3 G Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> (---"-14273 ®Toler of Springdale <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) \ <br /> `v' � `�New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other tvtodification to Existing System(explain) <br /> •/ Lisl Previous Permit Number and Dam Issued <br /> II. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expimt ion Owner <br /> IV.Type of POWTS Systetn/ComponentlDevicet (Check all that apply) <br /> ❑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.DlspersallTreatment Arcs Information: Dispersal Area ro axed{sq System Elcwtion <br /> Design Flow(gpd) Design Soil Application Rale(gpdsl) Dispersal Area uirrd(s0 spars P <br /> 450 yAr.k I '7` 456/f <- 103.3' <br /> VI.Tonic Info f Connelly in Totoi g or Manufacturer <br /> Gallons Gallons Units $Pr Ail _ 2 -� <br /> New Tents Existing Tanis c-U m'� 'sr, s.O i <br /> Septic or Holding Took 1000 1000 1 Crest X <br /> Basing Chamber 600 600 1 Crest x <br /> VII.Responsibility Statement-I,the ooderslgaed,•-- me responsibility for Installation of the POWTS shown on the attached plans. a Number <br /> Plumber's Nome(Print) P. ,,-'s Si_ / MMMPRS Nurpber.-_---Business ,�( <br /> a13 is mitt.- - - --/t` W..../Lt,ZQ Ci`-7`---. <br /> PI bet's Address(Sired,City,State,Zip Code) '.. <br /> � <br /> -7b9' ((1170 & 6,(7 o 1)s- <br /> ' 0358 ...( <br /> VIII.County/Department Use Only <br /> t� Permit Fee Data issued J Issuing nt Signature `--�._ <br /> td�Aoprvved I❑Disapproved S/O/�J L �(/ �-� <br /> jl❑Owner Given Reason for Denial �r �J/� �' <br /> IX.Conditions of Approval/Reasons for Disopproval I <br /> .(I <br /> Alta eh to complete plans for the up tent and submit to the County only on paper not less than A la r I t Inches In size <br /> SBD-6398(R.11/11) <br />