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"`—r"Q: County/ J <br /> 1 1i <br /> Industry Services Division DANE <br /> ,,.. )-' <br /> l 1400 E.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 1 3. a o17-- 00 ' -'7( <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 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(lxm),Stets. <br /> I. Application Information-Please Print All Information OLD 69 <br /> Pro er's Name Par <br /> etfr <br /> PATRICK& MELODY MULHALL '.✓"0507-361-9650-0 <br /> Property Owner's Mailing Address Property Loc n e".... <br /> W5254 HIGHLAND DR. iE%SE '/,, NE ''A, Section 36 <br /> City, State, Zip Code Phone Number <br /> NEW GLARUS,WI 53574 T 5 N,R 7 E <br /> II.Type of Building(check all that apply) /'- Lot# Subdivision Name <br /> ( or 2 Family Dwelling-Number of Bedrooms Block# <br /> ❑Public/Commercial-Describe Use — CSM Number ❑City of <br /> ❑State Owned-Describe Use ❑Village of <br /> �/ <br /> ErroWn of PRIMROSE <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [Th1 'System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B' ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> t <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground A.t-Grade ❑Mound>24 in.of suitable soil ❑Mound 5 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 Appli tion Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 0 0.6 • 000 1010 93.8 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks 4) o u E u p 6' - <br /> CSeptic or Folding Tank 1250 1250 1 CREST X <br /> Dosing <br /> Chamber I 750 750 1 CREST X <br /> VII.Responsibility Statement-I,the un ersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu is S' e MP/MPRS Number Business Phone Number <br /> TRAVIS G. DeSMET 1002082 (608) • 2- ••7 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> DeSmet Septic&Excavating, N7869 County Highway D, Belleville,WI 53508 - <br /> / <br /> VIII.County/Department Use Only v .1 ��/�� <br /> pproved 4 Disapproved Permit Fee Date Date I-.ue. ��/�•: c'�gyj`��� <br /> D Owner Given Reason for Denial $ / -1 C // ' —/��__ <br /> IX.Conditions of Approval/Reasons for Disapproval .010111.11W <br /> F.T. CIAP,4 17C. ft, (,-1,% / 3- J4t6 - t7o3.YS' ✓ si <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 xil 1 inches in size <br /> SBD-6398(R.08/14) SCANNED 1 .': � j_ ,...,,,/ <br />