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County t, a „ `,i. 7 i <br /> Safety and Buildings Division /Zit <br /> '.0 S G?; 201 W.Washington Ave., P.O.Box 7162 Sanitary Pernut Number(to be tilled in by Co.) <br /> i P I n rr � <br /> Madison,WI 53707-7162 <br /> . � ���-- mgr asDl ? � f3 <br /> State Transaction Number <br /> San tary Permit Application <br /> In accordance with SPS 333.21(2),WWis.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 /> 6 k.e A'6,1 t i �� chi' <br /> I. Application Information-Please Print All Information Parcel <br /> Property Owner's Name <br /> i ��• a.- Lee ii' " Al,1'zk<� 0:51e - 1/`( ' ert�&c3 - 0 <br /> Q�Ci r'� 1� � t-f'�/� <br /> Property Location <br /> Property Owner's Mailing Address <br /> ) S'v2-e (3 L' r r9) /7r rt9 (6;1 Govt.Lot <br /> City,State Zip Code Phone Number s5 LtJ v, 5/..:": h, Section I/ <br /> C (circle one) <br /> >���cG /)��t Pi ��f - '� T ,S N; R /0 EorW <br /> II.Type ofBuilding(check all that apply Lot it <br /> . Subdivision Name <br /> I or 2 Family Dwelling-Number of Bedro' ) <br /> Block 14 <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use ®Town of ,n u';t_/(+/'/d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Other Modification to Existing System(explain) <br /> ®New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only <br /> List Previous Permit Number and Date Issued <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> [V.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 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: p System Elevation <br /> Design Flow( pd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) Sy <br /> ZrGG t <br /> `f /5-0 0 15-1 1- /00,<i -/a<). 3 - 4 '. - <br /> VI.Tank Info Capacity in Total it of Manufacturer <br /> V <br /> Gallons Gallons Units ,o °v H <br /> v <br /> New Tanks Existing Tanks , ^ . ' ,, D ` 4 <br /> a U fn 5 rn iz_v E' <br /> Septic°a-Welding Tank 2 ( l ( ?to <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume respo,sibilit„far-installtation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum ee&-Signature ''----7 ) MP/MPRS Number <br /> STEVEN R. CROSBY „/.., _ c 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 7361 DARLIN DRIVE, DANE, `13 29 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issue Issuing a 4t na <br /> PLA.pproved ❑ Disapproved $ py � � (� <br /> ❑Owner Given Reason for Denial 1 <br /> ' IX.Conditions of Approval/Reasons for Disapproval <br /> F.T. r-rte' )- 1-gal the lg t/!s 11 inches in size /+ f /�.. <br /> Attach to complete plans for the system and submit to the .gunny ct t, :; <br /> Public tic:4th Pll. <br /> SBD-6398(R. I.t/I I) Environmental !'IL.H!'"t <br />