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. *�ftTllky , County <br /> 4.,,,o....--' <br /> N 4G Safety and Buildings Division 0-Aisle le4 I <br /> r x/ .s.„ / �0 i 201 W.Washington Ave.,P.O.Box 7162 Sanitary R., Number(to be fisted in by Co.) <br /> ,k` $; J f (,, Madison,WI 53707-7162 <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 tbrms 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(1Xm),Slats, <br /> L Application Information-Please Print All Information Ka 1'-in6c-fe q..5 ' <br /> Prope wner's Name f. • Su -., Parcel# <br /> )'rcd-54,r v4t"2/ CL Pin LiJa6 ,r > Iii-- f 'f--I,SVV-0 <br /> Property Owner's Mailing Address Property Location <br /> S/he'7 / 4 r+ `N, ..r i'2 3 (2 AeJe Govt. t , <br /> City State V Zip Code Phone Number <br /> :+6`/'e`C��' (E{.1.- a lSl ./� S 2 �., Section ' <br /> (circle one) '; <br /> ,I�L Type of Building(check all that apply) Lot# <br /> T 1 N; R f/ EorW . <br /> 0-.1-or 2 Family Dwelling-Number of Bedrooms Subdiv ion Name <br /> Block# / /a0 rf2 SPA IS If;d2le <br /> CI Public/Commercial-Describe Use ❑City of f <br /> ❑State Owned-Describe Use GSM Number ❑Village of <br /> Down of ar"' 4,01 <br /> III.Type Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. t' System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal. ❑Permit Revision 0 Change of Plumber ❑Permit Transfer to Now List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device:jcheck all that apply) 6,. -- <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade a Mound>24 in.of suitable soil AMotuul<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Info thin: <br /> Design Flow d) Design Soi placation Ratc(gpdsf) Dispe Required(at) Diapers a Proposed(st) . System Elevation ' <br /> Okada ate. lv0V 107 7 5- /a fl. 4, <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units <br /> New Tasks Existing Tanks w <br /> Septic or Bolding Tank 1 .) .3'C. tt�4 P l 147 L1° � <br /> ` Dosing Chamber <br /> 6 4.z a I de te-. <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) • Pltunber_.s.S( MP/MPRS Number , <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e) <br /> 7361 DARLIN DRIVE,DANE, WI 53529 i <br /> VIII,County/Department Use Only �..� <br /> p Disapproved ' Permit Fee Date ued issuing•ice .',:;stun <br /> roved ❑ Die <br /> ❑Owner Given Reason for Denial ��'"° 7 iy , -A -- ...., <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> REC IVED <br /> JUL 12 2017 <br /> Attach to complete plans for the system and submit to the County 0517 y _ NNE lelNblic Health MDC <br /> V1,//�� nvironmental Health <br /> SBD-6398(R. I tit I) <br />