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iojreariuv. County <br /> 7�;�' �� Safety and Buildings Division ()A n e 13 et.� <br /> l3i , 201 W.Washington Ave:,P.O.Box 7182 Sanitary Permit Number(to be filled in by Co.) <br /> a $ .''r <br /> 1 ....PS, t' 1 Madison,WI 53707-7182 <br /> Ni• <br /> Rw;r�r 11)' >c.b- x0 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submisston of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application terms for state-owned POWTS are submitted to Protect Address(if different than mailing address) <br /> the Department of Safety and Pru&ssional Sorvies. Personal intbrmation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(lxm),Stets. <br /> I. Application Information—Please Print All Information T.i,si 1,1e.chum Trdr i <br /> Property Owner's Name Parcel# <br /> fuelbledoutn taeue kvinerpt 070&- aq.3-ai5T'"b <br /> Property Owner's Melling Address Property Location <br /> 7626 Y Tu t•t b le oRO ru n Tr Govt.Lot <br /> City,State Zip Code Phone Number <br /> /VW y, $w 1/4, Section ,2 9 <br /> Ue roneti CV 5 3.5-1) (circle one) <br /> II.Type of Building(check all that apply) <br /> Lot u .T 7 N; R 8 S or W <br /> ig Ior2 Family Dwelling—NuotterOfBedrooms Jr / g Subdivision Name <br /> Block Tunr ble dawn ,eMc3' <br /> ❑Public/Commercial—Describe Use ❑City of <br /> • <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use ®Town of 11 pt tg k{o n <br /> III.Type of Permit: (Check only one box on Tine A. Complete line B If applicable) <br /> 's'' iti New System ❑Replacement System ❑Tratment/Hoiding Tank Replacement Only tx Other Modification to Existing System(explain) <br /> . B. ❑PotmitRenewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List PreviousPreviousPermit Number and Date Issued <br /> an <br /> Before Expiration Owner <br /> [V.Type of POWTS System/Component/Device: (Check all that apply) <br /> Eg Nen-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/T-reatment Area Information: <br /> Design Flow(spa) " Design Soil Application Rate(gpdst) Dispersal Area Required(si) I Dispersal Area Proposed(si) I System Elevation <br /> 7526 i y f 8'2 S I /q0g I 9.1f,c, — 5,41,6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> i Gallons Gallons Units <br /> New Tanks Existing Teaks y <br /> Ueda or Bolding Tank /to 5'6 /65'0 I /r oct40 Dt' <br /> Dosing t7>ernber /060 /000 1 _ /h e a�8� i <br /> ViI.Responsibility Statement-[,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> ' Plumber's Name(Print) Plum s Signs. , MP/MPRS Number" 1 Agge STEVEN R.CROSBY `i-__._ 227009 608-849-8771 <br /> Plumber's Address(SUoet,City,State,Zip Coda <br /> 7361 DARLIN DRIVE,DANE,WI 53529 <br /> VIII County[Department Use Only <br />` l�Approved•' ❑Disapproved Permit Fee Data issued Issuing Age, ignature <br /> 5 <br /> ❑Owner Given Ranson Om Denial U 3l 2 � . 0°..v �r`1,.�IX.Conditions of Approval/Reasons for Disapproval / '* t + <br /> FEB t 1 2011) <br /> t- purr C' <br /> • <br /> Attach to complete plena(or the system and submit to the County only on not el t {1 I IndhilY.l411A"' ' '- 1�o41r7`1 <br /> fir.4--- <br /> S B D-6 3 9 8(R. I I/I t) <br />