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anriiAYr County P� � ,Safety,and Buildings Division P 0,4e_ t4 <br /> r�, ` t 201.W.rWao.i,o gton AV$..,P.O;:Box 7182 Sanitary Permit Number(to be filled in by Co.) <br /> t"` :,:. ; �( . .Madison.WI-:53707-7162" <br /> ?t,... _:. .�f ;_dvr,�- eve 3• <br /> wt�� E <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 end Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Lawns.15,04(I)(nt),Stets. / V3 I,. �� <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Nta-h0iAS He//e-A-1r41t 4 ,4' 1761,1 ,'o //4 01, , A9,5 . e cb k er,, 70 -'6 <br /> Property Owner's Mailing Address Property Location <br /> e er r r v A , /'j ri ,Q`�C Govt.Lot <br /> City,State 1 Zip Code Phone Number /'f f Vs At is v, Section r? <br /> MtV)--141L6 ' 5 '3 t 4 ieore) <br /> �7 T N; R E or W <br /> � 1 E.Type.of Building(check all that apply) +� Lot <br /> J•4�' or2 Family Dwelling—Number of Bedrooms J' j Subdivision Name <br /> d' Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CS Number �r .E❑�Vr Village of <br /> i a� 4,. l , rlownof offl A '-ir"ft;4 ie <br /> III,Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t'' ❑New System 'placement System ❑Treatment/Holding Tank Replacement Only I Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑°,r.uit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before ExpiiratiOn Owner <br /> IV.Type of POWTS System/ .nponeat/Device: (Check all that apply) <br /> 941on-Pressurized In-Ground . L Pressurized la-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound a 24 in.•afeuitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Devtce.(explain) <br /> V.Dispersal/Treatment Area Informattow <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(At) Dispersal Area Proposed(sf) System Elevation <br /> 1:5-b. I el / qo 6, I 9er a Y4. ,Q , <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units '$ <br /> New Tula Existing Tanks <br /> Septic or Holding Tank /a.6 . ' !07 4.- ' At 4 4/ <br /> Dosing Chamber 4 64 I _ VFa 41t rye" . <br /> VII.Responsibility Statement- I,the undersigned,assume res.onsibtltty for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) • Plumb Si.,:.• y MPIMPRS Number ' , <br /> STEVEN R. CROSBY -. 227009 608-849-8771 <br /> t� — <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, SW 53529 <br /> 7 County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date issued Issuing S elute <br /> 0 Owner Given Reason for Denial• `��t 6 •Z4/r7 je....„\\._ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> !UN 21 2417 , <br /> Attach to complete plans for the system and submit to the Co <br /> ll Inches la.sise <br /> SCANNED Public Health MDC <br /> SBD-6398(R. 1l/1I) a19vtrO ?l�ant�l ieaith <br />