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it <br /> `as n`r'\` County <br /> I ;='; `4-_.,'�\"'y\ Sa fetcand Buildings Division 0a n� ►T•rs! •$ ;;; 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �`1 Madison,WI 53707-7162 <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(1)(m),Stats. <br /> I. Application Information—Please Print MI Information 2,Cr rr CQ e'r L0 Z.e <br /> Property Owner's Name Parcel# <br /> -Se,tg K p 0 0 0712 - XII - tell)--Cr <br /> Property Owner's Mailing Address Property Location <br /> 5-7 1(2. 0 h « w C&fh a "re`a tt 1 Govt.Lot <br /> City,State .l Zip Code Phone Number <br /> /L 6 '/, /1/15 IA Section 01--/Il t o-n o n u 1�T 3'7 1 y T 7 N; R 1 or <br /> (circle one) <br /> U.Type of Building(check all that apply) Lot# <br /> • <br /> 0-1 or 2 Family Dwelling—Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ' ❑ Village of <br /> '3 3 a ®Town of �•ee es Vr e is <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 ❑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 /> 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 6 o 0 / LI /.-Do /5-oo Ft,1 8`1,6, <br /> VL Tank Info Li in Total #of - Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ', c — <br /> c B <br /> a U N <br /> q y i.(� a <br /> Septic or Holding Tank 1 / eQ A <br /> Dosing Chamber <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for Installs ', o the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's•'fit. re (--- - MP/MPRS Number 1 <br /> STEVEN R. CROSBY 41,0. 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) Q• <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued [ssuin Ag�t igna ro } 4 ' <br /> ❑Owner Given Reason for Denial �� - lf'6-2o/s— <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x II Inches In size <br /> SBD-6398(R. 1 l/l l) <br />