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` , County <br /> j/5-,'0 \R `. q q' , I V Ind Buildings Division sbi¢rt1.�� <br /> $ P?� 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `•,t, P$ '�� 4� �, A G 0 3 2016 Madison,WI 53707-7162 <br /> i� <br /> pF /c 3 <br /> d�� _ Ja <br /> asei Public ealth MDC i • <br /> Sanitary 'ermi aAT 1CTication 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 /> . .oses in accordance with the Privac Law,s. 15.04(1)m),Stats. I-----,,,� <br /> u <br /> L Al,lication Information—Please Print All Information free e. <br /> Property Owner's Name Parcel N <br /> 17 f2 72' rr U3fi' p$41 b - 07'vi- $ k <br /> - <br /> Property Owner's Mailing Address Property Location <br /> .5-3,/ _3.- , - , PL Govt.Lot <br /> City,State Zip Code Phone Number <br /> 1/4a.4/61-1 1/4, Section 7 <br /> - :: f'4 6 <br /> 4 do Ka `W _ T ( N; R /(circle oceW <br /> II. ype of Building(check all that�ppl )Lot N La <br /> 't.'or 2 Family Dwelling-Number of Be. ooms ,-3 Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> -- ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 4g-Town of se)#.4..14 44-x44 <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> IVew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0'Other Modification to Existing System(explain) <br /> ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T .e of POWTS S stem/Com,onent/Device: Check all that a..1 <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized[n-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil A found<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis'ersal/Treatment Area Information: <br /> Desi -Flow(gpd) Design Soil plication Rate(gpdsf) Dispers Area Required(sf) Dispers• • ea Proposed(sf) System Elevation <br /> `f /> a , 7.-r p s7-1— / , 3 <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units °' <br /> D- N U <br /> New Tanks Existing Tanks <br /> a v V y <br /> -,. o 5 .NV. a a <br /> a U im H to ii 5 i% <br /> r.eptiq 6r Holding Tank /d S)y 9' f d a° t <br /> Dosing Chamber <br /> <.3...Q:=, j /s MEM <br /> VII.Responsibility Statement- t,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) MP/MFRS Number <br /> STEVEN R. CROSBY 227009 <br /> ��� dr 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) �� <br /> 7361 DARLIN DRIVE, DANE, WI 3529 <br /> VII 'Count /De.artment Use Onl <br /> Approved ❑ Disapproved Permit Fee Date Issued. Issuing A <br /> ❑ Owner Given Reason for Denial $/ 9 .? /.�/t \ <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 11 inches in size <br /> scANNEr <br /> SBD-6398(R. l l/1 l) <br />