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„ n-`\r County <br /> ,,,,-.,:::::-1:1 J t Safety and Buildings Division C«2e 73 AN. <br /> =` •:=D s A,�j e q 201 W.Washington Ave., P.O. Box 7162 <br /> St 4 p�- I<I _7 9 Sanitary Permit Number(to be tilled in by Co.) <br /> Madison,WI 53707-7162 <br /> • <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 6,5 Hw y k <br /> Property Owner's Name Parcel M ✓ ✓6267j• <br /> kussetl leall U19 Octb7 - Pl3- .0 -- • <br /> Property Owner's Mailing Address Property Location <br /> 6 5-5-6 C Itw,j K19 <br /> Govt.Lot <br /> City,State Zip Code Phone Number /1/14, y. 5 w /., Section 3 V <br /> lift 2OX'l cui C e LO 's 3 S 6 G p circle one) <br /> II.Type of Building(check all that apply) Lot# fT l N; R 7 ( E or <br /> gi-1 or 2 Family Dwelling—Number of Bedrooms 3 , Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commercial—Describe Use <br /> ❑City of 3 <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of I <br /> J ct Town of n )C b to v'y i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. <br /> Q New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only rj 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 /> 1 <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) ✓Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> pis U , L( // V-r // s S- r45, y 9Y•G 31S_, <br /> VI.Tank Info Capacity in Total fl of Manufacturer <br /> Gallons Gallons Units ` o - o <br /> New Tanks Existing Tanks .L e u Ijm y a g <br /> L N <br /> n, <br /> a U � �, � iZ 3 iY <br /> Septic or Holding Tank /oU 0 r <br /> /000 1 Plea c4-e g <br /> Dosing Chamber - <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb ers gn 7 MP/MPRS Number <br /> STEVEN R. CROSBY ', 227009 I <br /> / 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> vl .County/Department Use Only <br /> y_ Approved ❑ Disapproved Permit Date Issued Issuing mature <br /> 0 Owner Given Reason for Denial ` 3 2 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> :cCCEIVE :) <br /> FEB 2 8 2011 <br /> Attach to complete plans for the system and submit t t Pt,+b! -Hcalth l Health <br /> P p r �����ttt ` °8”:``tE"ftliii t zenentaI Health <br /> S BD-6398(R. 1 1/1 I 1 <br />