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<br /> I
<br /> � roeunr,h N County /' I
<br /> ,(17.'11 , \ Safety and oSulidings Division ,�4 A/,p ���
<br /> S ' �y �01'VV.Washington Ave.,R.O.Box 7162 Sanitary Permit Number(to be ailed in by Co.)
<br /> `yt p S Madison,WI 53707-7162
<br /> �,a: i t -a O t) CO�r�RI
<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•awned POWTS are submitted to Project Address(ifdifferent than mailing address)
<br /> the Department of Safety and Professional Service. Personal Information you provide may be used for secondary v., �^
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets, J�{� ) ,
<br /> I. Application Information—Please Print All Info rmatlon ""1 p ,'per fie~
<br /> ,property Owner's Name Parcel#
<br /> tfPAt,I a;l-rt.,,rc 1 4/,c4,2, Rt,74+ (3711- ov-Y- e7i7$-.0
<br /> !weeny Owner's Mailing Address / j� 5� Property Location
<br /> If 7Z) Rein 4ara C lie.. )i 1 Pis Govt.Lot
<br /> City,State Zip Code Phone Number VP/4A, ,, S ..',Section 9.--
<br /> Af4 /'.D it. W y J (circle one)
<br /> U.Type of Building(check all that apply) Lot T N; R /� S or W
<br /> ❑1 or 2 Fondly Dwelling-Number of Bedrooms
<br /> Subdivision Name
<br /> Block#
<br /> ❑Public/Conuaercial-Describe Use ❑City of
<br /> ❑State Owned-Describe Use CSM Number 0 Village of ed./744r
<br /> !ff 'p'L,F Pown of C r!a'f��
<br /> III.Type of Permit: (Cheek only one box on line A.. Complete line B If applicable)
<br /> A. yew System ❑Replacement System ❑Treatment/HotdingTank Replacement Only Or Other Modification to Existing System(explain)
<br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New LLst Previous Permit Number and bete tossed
<br /> Before Expiration Owner
<br /> IV.Type of POWTS Systern/Component/Device: (Check all that apply)
<br /> .gbNon•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 w(gpd) Design Soil Application Rate(ggpdst) ' Dispersal ,reaRequired(st) Dispers0.-Area Proposed(so SyslemElevation s
<br /> �� f� ✓✓ld'? S ✓✓i Y� t/tot,4 lor1.? It.-
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units i °V a
<br /> New Tanks Existing Tutu V e GB T .2 l
<br /> /
<br /> a.r.) rota rn •wG a
<br /> Septic or Holding Tank f!� 16 t //�s4.d� .a
<br /> DosiagOiambat / • 1-
<br /> 1
<br /> VIL Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plum., t re MP/MPRS Number
<br /> STEVEN R.CROSBY ,..�',,,..�_ 227009 608-849-8771
<br /> �..-frari�
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7361 DARLIN DRIVE,DANE, 53529
<br /> VIIL only/Department Use Only
<br /> Approved 0 Disapproved De Permit Fee Date(ssue tssui atura i
<br /> ❑Owner Given Reason for Denial $ qDt.‘ (ct'' 03//7 /,,9;
<br /> IX.Conditions of ApprovaVReasons for Disapproval
<br /> RECEIVED
<br /> Attach to complete plans for the system Ned Submit to the County on on a � 1��
<br /> P P ty N paper not less than glas It lecher heart
<br /> Public Health MDC
<br /> SBD-6398(R,I L/I I) Environmental Health
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