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" ' County <br /> /3"--7'n1 R 9 Safety and Buildings Division 04 AZ_ <br /> 1.4?to$ 1� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '• P ''! Madison,WI 53707-7162 <br /> s 4 �� <br /> :w� <br /> •�:ti - . 13-:30/6-0o3I0 <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 ybe used for secondary y� <br /> purposes I. ApplinaionInfemaioe-PleaeP,itAltI)for.Slats. (�FCEJ�VED .shy &r)g`."tsa� rd, <br /> I. Applicationinformation-PleasePrintAlllnformation K <br /> Property Owner's Name Parcel# <br /> ••• -7-4'1 •* MIf-re P�<- rgve-X OCT 062016 0866– ...7y,i,. 5.73t–c> <br /> Property Owner's Mailing Address Property Location <br /> r� Public Health MDC <br /> 7 i V 17 5/- Eci q•& P r' Environmental Health Govt.Lot <br /> City,State Zip Code Phone Number .,f.£•• /, N,: '/, Section a}g <br /> /724 7,4A?etr71 °...ti 4Y'� 'a (circ ..,e) <br /> U.Type of Building(check all that ap ` Lot# <br /> T N N; R b !W <br /> op I or 2 Family Dwelling-Number of Be ms (�,i1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of T2 <br /> ffil..Town of )3J 4 c-k i Or -k <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I rp New System ❑Replacement System P y p y ❑Treatment/Holding Tank Replacement Only CI Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Permit Revision <br /> ❑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 appl ) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade vtound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> luau a,b 2>rs00 /8?.3- 9 /3— <br /> VI.,Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units V `o o <br /> New Tanks Existing Tanks to u m 3 Ss` Q •2 <br /> / yam/ <A'" <br /> Dosing iT: H in ia.C, iL <br /> Septic nnS{eidt�Tank 1 a e 4. — /a 8i. ) / e-4L . <br /> Dosing Chamber to.S cs — 4.5-t, y <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signatur MP/MPRS Number <br /> STEVEN R.CROSBY / -` --- 227009 <br /> 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 S l t ePerm 4to Permit Fee Date Issued Issuing n.! <br /> ❑Owner Given Reason for Denial /Oir7/''.ZNI6 C Aigier- <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> --> uP - A R12zy F <br /> P0sx <br /> -->r o r*c,l r� (1r v�, ,( 40 <br /> FAT Dou.,,,,,t /.2.a,..4'1 <br /> loft y/9c o.J/ f% 6ry-C 9 0.Pe-06+44k 74 e-r <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 its z I I inches in size <br /> SBD-6398(R.t I/I I) <br />