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Rx Date/Time RPR-06-2015(MON) 07: 50 6088506848 P. 001 <br /> 04/06/2015 07:49 FAX 6088506848 Septic Specialists Z001 <br /> 2" :�riir�r County <br /> /41 :s.,;,.. �\ Safety and Btiiidings Division _ QCtri :sH <br /> •r 201 W,Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled In by Co.) <br /> `�t P.A, `) Madison,WI 53707-7162 <br /> �T1NN?i <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code.submission of this form to the appropriate governmental unit <br /> Is required prior to obtaining a sanitary prank. Note:Application fortes for state-owned PO WTS are submitted to Project Address(i amore t then mailing address) <br /> the Department of Safety and Professional Servies. Personal inmtmadon you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,e.19.04(1Km),Std. . <br /> I. Application lnfortnat lee-Please Print All Information Ern e lc Oro v . <br /> Property Owner's Name Parcel li <br /> i Oar,t'd� 44 !.vend 11�� ,- 'o I r n e Oct l f- 30 3~ oft�`l1 _ o <br /> Property Owner's Mailing Addroks Property Location <br /> 3 0 3 ' ill ra k e r Vuf . Oovt.Lot <br /> City,State Zip Codc Phone Number <br /> S e= y, ,Sty '/a section 3 O <br /> SG n Pro.f,•t a (,l/ c 3 5-ci O (circle one) <br /> II.Type of Building(cheek all that apply) Lot k T 4 N; R // E m W <br /> • <br /> ® Bedrooms or 2 Family Dwelling-Number of Bedrocs, y .,I Subdivision Name <br /> Block0 a rl'6+0r tsOrdPh S <br /> 0 Public/Commercial-Describe Use - ❑Cl ry of <br /> ❑State Owned-Describe Use rCSM Number ❑Village of <br /> ®Town of Cyr s 1o/ <br /> IIL Type of Permit: (Check only one box on line A. Complete tine B If applicable) <br /> A' B New System ❑Replacement System 0 Treatment/Holdlag Tank Replacement Only 0 Other Modifonion to existing System(explain) <br /> i <br /> I <br /> I B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber 0 PetmitTransfer to Now Lut Proviotu PermltNumber end Date issued <br /> Bctbro Expiration Owner <br /> fV.ape of POWTS System/Component/Device: (Check all that apply) _ <br /> Ig Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>_24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Disperse'Component(explain) ❑Pretreatment Device(explain) <br /> V.Dlapersa$/Treatment Area Information; <br /> Design Flow(gpd) Design l•AppllcIticc Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(at) System Elevation <br /> Gov 1-/ /5-o a .. R8,0 415 Y0.o c(6.5 <br /> VL Tank Info Capacity in Total p of' Manufacturer <br /> Gallons Gallons Units g g o <br /> New Tanks Existing Tanks if 8 I <br /> E8 in i o Li al <br /> • septa or How.,Tag /;z F'G 123'6 / MO a BP <br /> Dosing Chamber ?O U Pa u / rn C 4 <br /> • VIL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached platy. <br /> Plumber's Name(Print) Plumber's.S , MP MP/ RS Number <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 Ilso Only I <br /> u <br /> /: pproved ❑Disapproved <br /> Fee Date issued Issul /Agent Si:. t . <br /> 0 Owner Given Reason Ibr Denial 43I 4, •�� <br /> IX.Conditions of ApprovaVReasons for Disapproval ` / � <br /> 14644„6,,A1 L-1 AZi ../'t c (& 5 ILA-Ii ._ 4 <br /> • <br /> • <br /> Attach In complete plans far the system led submit In eho County only on paper net less than a errs l l loch..In site <br /> SSD•6398(R. l i/1 l) <br /> • <br />