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<br /> evii;azirty County
<br /> is '�\4, Safety and Buildings Division 4>a soy! vor
<br /> js, S t 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> ?v,,,, pS 1) 'j IM Madison,WI 53707-7162
<br /> ,� ��L
<br /> d m of 7 - 0,0 `5'x'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 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(l)(m),Stats. ,' y j/�, Q
<br /> I. Application Information—Please Print All Information r !7 'y
<br /> Property Owner's Name Parcel It
<br /> a b r.-i f d- I r111.1--41 D;4 k , ' a 5.4.11. go / - 94.6/ - ss
<br /> Property Owner's Mailing/Address Property Location
<br /> 1-` N 65— /'j/f a i 1 GiJo-*ti D Govt.Lot
<br /> City,State / Zip Code Phone Number is'},,, / /VA 4, Section r7
<br /> Orel 0 A s . lr2" 53-,-7.� l �o(ci a one)
<br /> W TN; R [ W
<br /> IL T pe of Building(check all that apply) �'`, Lot#
<br /> Apt or 2 Family Dwelling—Number of Bedrooms
<br /> 3 I Subdivision Name ,
<br /> Block#
<br /> ❑Public/Commercial—Describe Use
<br /> ii City of
<br /> ❑State Owned—Describe Use CSM Number ❑ Village of c�
<br /> wn of Q4' 5.A
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. 'New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only rif 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 /> ,n-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/Treatment Area Information:
<br /> Desig4low(gpd) D,gsign Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal..Area Proposed(st) S tem Elevation
<br /> ` v., ,fc*, 1:.5 6, 5- ter) , lac i" q<<v 941'
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units ! o d g
<br /> New Tanks Existing Tanks E c u g 4t .3
<br /> n.0 in . 0 'w0 4
<br /> Septic or Holding Tank rf,/0 d7 4 /000 / /17 e..4.1 4--
<br /> Dosing Chamber
<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 ' ignature MP/MPRS Number .
<br /> STEVEN R. CROSBY 227009 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 7361 DARLIN DRIVE, DANE, r529
<br /> VIII.County/Department Use Only _,----C--------
<br /> litt Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature
<br /> $ U. �'
<br /> .� , \� -il '0\a ( ' ' '„,„L r 6- /t. .
<br /> ❑ Owner Given Reason for Denial � 0 -.
<br /> IX.Conditions of ApprovalReasons for Disapproval t ` a
<br /> ay
<br /> 0f:' 0 4 7717
<br /> ,.:>i;.. h:.,:*, kc,c
<br /> Ftwic GJ Wca+th
<br /> Attach to complete plans for the system and submit to the County only on paper not less tb*n s 1/2 X II inches in size
<br /> SBD-6398(R. l 1/11)
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