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,xaT , County <br /> `% �'',.`. Safety and Buildings Division °One <br /> ' 4X/� ; ;\•',\ 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Is' ;S ' ;'/` U Madison,WI 53707-7162 <br /> `\'4, ;:';1;$ ,!'; RECEIVED /5 20 15- 3 <br /> '4• <br /> Sanitary Permit Applicatio1 EB 17 2015 State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the pproprlate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS e[e submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you p?J llS W!�}' ii'foec condary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. Environmenta eal <br /> I. Application Information-Please Print All Information 't v_i nc' Or't✓e <br /> Property Owner's Name Parcel# <br /> b6h1" e ,S /ta e- 3.1a �)TY . )oPr14 e:/4 :Lim- /5Vi0--021,' oax3 - o <br /> �Prroperty Owner's Mailing Address Property Location <br /> LG? Ve, u /A 5 G e k_r ki e ' to l a 1 4-e ,�i�ctl�/ rci Govt.Lot <br /> City,S Zip Code Phone Number 7y r n, AA,/ %, Section .2 <br /> di) pd r t I e- S,.5-1 L. ) <br /> (circle one <br /> T cr N; R /0 E or e) <br /> II.Type of Building(check all that apply) Lot# <br /> Li 3 Subdivision Name <br /> r 1 or 2 Family Dwelling-Number of Bedroom <br /> Block# Gehrke /S k,,ol/ <br /> ❑Public/Commercial-Describe Use ❑City-of -- -- - <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> 0 Town of eU"l<- <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> mg New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision CI Change of Plumber ❑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 /> ❑Non-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.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 60 0 -cr 0. I'G ' I r k} et e 1 I 17`61 ,oa, 9 - <br /> VI.Tank Info Capacity in Total #of 6tanufacturer <br /> Gallons Gallons Units 0 U° y -' <br /> New Tanks Existing Tanks u c P. g A 2.1.4 <br /> n et 'v, 11.t:7 G. <br /> < 5eptib or Holding Tank !a 5.6 /,t$'6 I /nee,(X r a( - <br /> Dosing Chamber $''Q Q n b / /'te ee GQ-e Pe <br /> VII.Responsibility Statement- I,the undersigned,assume-r sponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu ber's .-.1 e MP/MPRS Number 1 <br /> STEVEN R. CROSBY / 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> Permit Fee p/z Date Issued [s ing ignature <br /> Approved ❑ Disapproved <br /> ❑Owner Given Reason for Denial $ 1 a q(n(l" / 4''' �p / <br /> `(� Z r� !rS �E%! � —"� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I <br /> i <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 I/2 x l t inches In size <br /> SBD-6398(R. I 1 11/1 <br />