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.:i/p itr4gy County I <br /> •f ` Safety and Buildings Division iO n�° ..a''~`" <br /> w }} �� 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) I <br /> 1 T\ :Sa 0,,'!III) �o `l b' 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 asanitary 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, LS.04(1)(m),Stets. J <br /> I. Appl :Rios Information-Please Print All Information !-Oue 1 G r/ 4 55 <br /> Prope Owner's Name Parcel It <br /> 6 riurl iht lie,- 713P.- 3g -Li 7g-- o <br /> Property Owner's Mailing Address Property Location <br /> 500 /0C9 ii t'& P6 0 703 � �CrotLot <br /> City,State l ' " Zip Code Phone Number (..' +5 il/ +/ PC y,, Section 3 2-- <br /> /)i° !l e (,1 U e. W A 9., 0‘-i 4 (circle one) <br /> IL Type of Building(check all that apply) Lot# T N; R_ Ear W <br /> ®t or 2 Family Dwelling—Number of Bedrooms 1 71°2 SubLvioa Name <br /> Block# A c fen meadow • '.5i <br /> 0 Public/Commercial-Describe Use 0 City of <br /> 0 State Owned-Describe Use CSly[Number ❑Village of <br /> fil-Town of 1ntdel Iek'? <br /> IIL Type of ermit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only tl.Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized[n-Ground 0 At-Grade JMMfound>24 in,of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispers (/Treatment Area Info ation: <br /> oww <br /> Design (gpd) Design Soli plicat[on Rate(gpdsf) Dipper (Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> QCs d t 6 /dtso `T -ait 0 ie,s q",r <br /> VI.Tank Info Capacity in Total #of Manufacturer , <br /> Gallons Gallons Units i 1 CI/ .2.2 <br /> New Tanks Existing Tanks o .vi .11 <br /> n.0 n e, .1 wt,7 a. <br /> Septic or Holding Tank r■24 L 102 Y e ( /'l e(,i'L7g A/ <br /> Dosing Chamber 6 G Roo ( fk e a pie- n' <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown oa the attached plans. I <br /> Plumber's Name(Print) Plumber' IF••+fir MP/MPRS Number + <br /> STEVEN R. CROSBY 5- 1r- I 227009 608-849-8771 <br /> • <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> V I.County/Department Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued Issuin: :en_ '_ • <br /> I �} ..,..7:4 <br /> El Owner Given Reason for Denial $ l��b 0 p`+� /7 /:�'" •i e. <br /> IX,Conditions of Approval/Reasons for Disapproval t ". <br /> rb v'r <br /> r �f <br /> OCT• <br /> b Eilll <br /> Attach to comptute plans for the system awl submit to the county only on paper not less then 8 1/2 x I.!Inches In cite•, . ,,,c <br /> SCANNEDEilvitur nct,tiDi H-h.... lfh <br /> SBD-6398(R. 1 1/1.1) <br />