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`. .t.- —�rn County 1 <br /> /45/1^ \`t\ Safety and Buildings Division D449e -1F+('.� <br /> i.( A S �, 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> '`;. 's. j��i q3) Madison,WI 53707-7162 <br /> :' 13 -201 to--( jq(o <br /> `.-`71U`l&/ <br /> Sanitary Permit 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 R.7 7'0 t.��tt <br /> '1 Lrt 6T2 J5-3 Os <br /> Property Owner's Name rr�� Parcel# <br /> r 7 1 $ L.)'t>i t t...C 0 5 r ;$10(--/ 0)8- 3 V.3-45;7 3 -6 <br /> Property Owner's Mailing Address Property Location <br /> °2 eq V. 5 )1.7 F')-4,-t. b� Govt.Lot <br /> City,State ` Zip Code Phone Number <br /> �y p _ 4/ %,, .Sly '/�, Section `1 <br /> ,54$7\$7\ I t!`.4 9 f44- 5-3 `J 91.E �1 (circle one) <br /> T <3 N; R t( E or W <br /> II.Type of Building(check all that apply) Lot 4 <br /> j$i or 2 Family Dwelling—Number of Bedrooms i a Subdivision Name <br /> Block# 77-7c D4 k S <br /> ❑Public/Commercial—Describe Use <br /> CSM Number <br /> RECEIVED ❑city of <br /> ❑State Owned—Describe Use <br /> ❑ Village of <br /> JUL 0 7 2016 Town of S'un 7 t' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A Pt,bfc Health MDC <br /> tew System ❑E ertei Het'�thlreatment/Holding Tank Replacement Only 'Other Modification to Existing System(explain) <br /> B. L/ List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑q At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) G T -Pa u7 ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 150 . CS .)/ tifT /Q®,0 954> <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units o 'n o <br /> New Tanks Existing Tanks a = v g <br /> C.:E ) ., tZ <br /> U in y cis wC7 a <br /> Septic orPietilieg Tank l lb .t7:, TO f f '� I 4744d <br /> Dosing Chamber Y ✓I/ /' <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 ' attire 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 /> Approved ❑ Disapproved Permit Fee Date Issued Esau' Ag t nature <br /> ❑Owner Given Reason for Denial $'42 17 r-P 11-20/6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in size <br /> SBD-6398(R. I l/1 1) <br />