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iCounty <br /> x /j :+, Safety and Buildings Division 0�,,�, <br /> rY ''''41 D'P 1.i j ^, 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �.� S Madison,WI 53707-7162 <br /> ,•:-. __ :Y�^,i ...,.— —"°""'—_, <br /> �'t'yrx>r+,w: i }- d 0 1`7.-- cool) 17 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(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 l <br /> Property Owner's Name �rAV � i <br /> Parcel# <br /> � <br /> Z'' -Rttc.k 1 /}//lje/ t' <br /> 67/I -I,2x - br 790 -61 <br /> Property Owner's Mailing Address' Property Location <br /> I�/ E,an/i ci Govt.Lot <br /> City,State Zip Code Phone Number <br /> yy, t/JLI,,, +/.,!tilt+ %, Section /J . <br /> 1970 Q/�5 o /7 S L (circle one) <br /> H.Type of Building(check all that ap y) Lot# T 7 N; R // E or W <br /> 8 1 or 2 Family Dwelling-Number of Bedrboms .. Subdivision Name <br /> / Block# <br /> ❑Public/Commercial-Describe Use / <br /> ❑City of <br /> ❑State Owned-Describe Use CSty[Number 0 Village of <br /> c� /.2 � .Townof C O 0✓ e' 6foc'e <br /> / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' •New System ❑ Replacement System ❑Treatment/Holding Replacement Only g Tank lacement P y (21.Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑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 apply) <br /> ❑ Non-Pressurized tn-Ground ❑ Pressurized[n-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Apflicattiptf Rate(gpdsf) Dispersal Area Required(sf) Disco rsal Area Proposed(sf) System Elevation <br /> 7SO V 6-), / `2 1,.Z`c",' /5,7) y�, 3 t <br /> VI.Tank Info Capacity in 'Total #of Manufacturer <br /> Gallons Gallons Units v c <br /> C U <br /> New Tanks Existing Tanks ts t .,. . 'y <br /> c. U rn in a(.7 a. <br /> Septic or Holding Tank /G S O <br /> /Gre) I Mear9P . Ai <br /> Dosing Chamber <br /> 1000 /Ivo l fileaAPP vC <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for in lation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber 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 /> Permit Fee Date[sued [ssui Agent !r <br /> )proved :::: L/Reason for Denial 1).`i t 3 ri//) .W M dt.� <br /> e <br /> IX.Conditions of Approval/Reasons for Disapproval !op 0 3 2'17 <br /> Public Health MI)C <br /> Environmental Health <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/3 z t l Inches in size <br /> SBD-6398(R. I I/I I) <br /> fl <br /> , <br />