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E <br /> t irr County p / <br /> •. Safety end Buildings Division: Pa/V4- ►I r <br /> ■ r ,y\ 201 W:�Washiligton Ave.,PA.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ( $ . �< Madison;WI 53707-7162 <br /> \A ri::r$'iw i t.�s? <br /> �°fit' J)'"1 /3-el0 (7- fl <br /> n"a``i State Transaction Number <br /> Sanitary Permit Application <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 ProjectAddress(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.I5.04(I)(m),Stets. <br /> I. 7/ <br /> I. Application Information—Please Print All Information parcel# f / <br /> Property Owner's Name <br /> z, `7 r�„S I- C a;Jy,ti 1 Arl sl - c i s 4 e n e,1) o J, - .7 l r- 1 $ n '- b <br /> Property Owner's Mailing Address Property Location <br /> 3 t,f e.oL,�".i a r- Or Gawk Lot <br /> City,State /! Zip •.e Phone Number 1f.-i , N e-- 'A, Section °9 7 <br /> C�1 � 41-44 /�� (otrcle one) <br /> A 9�/' FD " e W ) T (a N: R /i3 EorW <br /> Q.Type of Banding(check all that apply) Lot# <br /> ,( <br /> ❑tor 2 Fam[iy Dwelling Dwelling � Subdivision Name—Number of Bedrooms r <br /> Block# <br /> El pub[ic/Cotmnercial—Describe Use ❑City of <br /> • <br /> W CSM Number Q Village of <br /> ❑State Owned—Describe Use Town of C-4-, i 0 <br /> 1'+r4;4 4 R <br /> i / 3 7 icr—3 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ew 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 <br /> List Previous Permit Number and Date Issued 1 <br /> Before Expiration It Owner <br /> 0.) IV.Type of POWTS System/Component/Device: (Check all that apply) I <br /> I <br /> /Ion-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 Ligation Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Dasi Soil App 4? D I' 0 ' Y i p<, /,,-l•a 47,a‘ 9 7,,t ' ' i e <br /> VL Tank Into Capacity in Total it of Manufacturer a <br /> Gallons Gallons Units <br /> Existing Tanks v.t7 0• <br /> New tanksyr /� , U A 0, rn <br /> Septic orf ntdleg Tank f'+^'f U �b .-'.—� i R8 fD '' t-e_1 d,4_ <br /> Dosing Chamber ! St <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 S' I. p MP/MPRS Number <br /> STEVEN R. CROSBY Jar 1 227009 608-849-8771 <br /> 4 de- - -j Plumber's Address(Street,City,State,Zip Code) <br /> 7361 MARLIN DRIVE,DANE, WI 53 9 <br /> VIII.County/Department Use Only <br /> Permit ee Date Issued .: Issuin ent S' slur <br /> Approved ❑Disapproved $ b°1 '3_2 2o17 C 2\1--e/f/K--- <br /> ❑Owner Given Reason for Denial } <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> I <br /> a FEB282017 <br /> Attach to complete plans for the system t/�tl�� or not less than 8 to x It incvi ro imHealth MDC/,r.����yy Environmental Health <br /> SBD-6398(R. t in l) , <br />