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\,.Nall i./.• �� County
<br /> • ",��' �0`�•, -v Safety and Buildings Division 1)4 (: J M
<br /> =' Q �`�' 201 W.Washington Ave., P.O. Box 7162
<br /> s $ t 'S g Sanitary Permit Number(to be tilled in by Co.)
<br /> \,.. PS '�, Madison,WI 53707-7162
<br /> i1
<br /> i 3 -.)o ,-7_ nto0 3-3
<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-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 k )irt 64.A;11 ;c c It
<br /> Property Owner's Name Parcel#
<br /> /Ai e-i/ e.i•, # Ann /Ira 6c_r)-0arz e----- 44v8 . 45.a .. Q,335. 6
<br /> Property Owner's Mailing Address Property Location
<br /> / 7 2 /'>'/�1/ . IY'-
<br /> Govt.Lot
<br /> City,State Zip Code Phone Number , , s '
<br /> (/11��/., /1/,(,tJ /., Section
<br /> y/ ,t. c.;t, (&,s '?) (circle one)
<br /> IL Type of Building(check all that apply) •to {,.�'A ,
<br /> T (p N; R ' W
<br /> ,l or 2 Family Dwelling—Number of Bedrooms Subdivision Name
<br /> // Block# ri,4 wpl.cL'i c�s1-WA AA::h 14,>V
<br /> ❑Public/Commercial—Describe Use
<br /> ❑ City of
<br /> ❑State Owned—Describe Use CSM Number ❑ Village of
<br /> r t/
<br /> Town of X tr6 4 A
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. r New System y ❑ Replacement System ❑ Treatment/[-Iolding Tank Replacement Only til 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 /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ' .1,, ound<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 A lication Rate(gpdsf) Dispersal Area Required(sE) Dispe.aal Area Proposed(sf) System Elevation
<br /> &,61:, t/ 45 , fv / a,.5,, 1/ 1687 9 7,3
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units ° o
<br /> New Tanks Existing Tanks y c 0 = « D ii "A
<br /> ri V ri H rn is-a a
<br /> Septic or Holding Tank ) /IL / 9+t t, 1 /774 fi 7 J
<br /> Dosing Chamber
<br /> �i4� fi0u 7 // J
<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 ' ature !' MP/MPRS Number
<br /> STEVEN R. CROSBY % 227009 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code) l
<br /> /_� --
<br /> 7361 DARLIN DRIVE, DANE, WIN,- 9 - !"`= -
<br /> V H.County_/Department Use Only
<br /> rI proved ❑ Disapproved
<br /> Permit Fee Date Issued Issui Agent S.1. �
<br /> ❑ Owner Given Reason for Denial I a 4 b 3 r 1 ��� . i
<br /> / 1�.�� �trwll ir__a=oraa.�
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> SCANNED �F�` 2 2017
<br /> Public Health MDC
<br /> ' Environmental Health
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2511 inches in size
<br /> SBD-6398(R. l lit l)
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