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County t\ y <br /> )1 4 <br /> /, ;,+,„:, �, Safety and Buildings Division Dane <br /> r t,1 t i ,, 201 W.Washington Ave..P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> a ''sp`:` "! Madison,WI 53707-7162 <br /> i �lli∎t a, 4/ <br /> Sanitary Permit Application State Tntnsaetlon 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 slate-owned POWTS are submitted to Project Address Of different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provido may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Sluts. 713 Kelly Drive <br /> I. Application Information-Please Print AU Information <br /> Property Owner's Name Parcel# <br /> \,The Bruce Company '0508-204-8500-7 <br /> Property Owner's Mailing Address Property Locution <br /> , P.O.Box 620330 I Govt.Lot <br /> City,State Zip Code Phone Number NW 1, SE ''V, Section 20 <br /> �•,Middieton,WI 53562 8 (circle one) <br /> T 5 N; tt E or W <br /> Ii.Type of Building(check nil(lint apply) Lot 0 <br /> ❑I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Biock it 40 Acre Parcel <br /> U Public/Commercial-Describe Use Employee Bathroom <br /> ❑City of , <br /> CSM Number ❑Village of <br /> ❑Slate Owned-Describe Use Montrose <br /> 1-�Town of <br /> III.Type of Permit: (Cheek only one Pox on line A. Complete line B if applicable) . <br /> A' ®New System ❑Replacement System ❑Treatment/Holding Tunk Replacement Only ❑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 nit that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<2.4 in,of suitable soil <br /> *Fielding Tonk ❑Other Dispersal Component(esploin), ❑Pretreatment Device(explain) <br /> V.Dlspersalffrentment Aren Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(si) Dispersal Area Proposed(sl) System Elevation <br /> 234 <br /> Vi.Tank Info Capacity in Total II of Manufacturer <br /> Gallons Gallons Units o 0 <br /> u t <br /> New Tanks Existing Tanks ag <br /> a u inn v, t£t7 a <br /> Septic or Holding Tank 2000 2000 1 Dalmaray x <br /> Dosing Chamber _ <br /> ViI.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POW 'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signaturq MP/MPtS Number Business Phone Number <br /> `--\--- tyw4A1 toi 'Se)/lie— 1'J�' �a7 5a 5 60 g -Sy 5`7ti6E <br /> Plumber's Address(Street,ally,State,Zip Code) <br /> 133 o Fr i42 - Rd • V t+t-ok)- -, WM.. 5'3 69 3 <br /> VIII,County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date isau Issuing Agent Signature <br /> $ 1O)O\ x(41611/ s . <br /> ❑Owner Given Reason for Denial � jteic <br /> IX.Conditions of Approvol/Rensons for Disapproval <br /> Minch In complete plans for the system and submit to the County only an paper not less than fl Ins 11 Inches in size i 1'i.`• i r, !till <br /> €. f { 1 <br /> SBD-6398(12~I lIl)) svk �- COViI )i i 1,:.:6...,.2 i 1,2zit(i <br />