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,► ieiimiri i'i;., s'' County <br /> ��.4:.,`;;-.-- <br /> _ ter'\ w Safety g <br /> ,,, \;� y and Buildings Division Oda e_ <br /> !`x Si. ' 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in liy Co.) <br /> V:\� ';-�' 1'� Madison,WI 53707-7162 <br /> 13 , 2o t -- ou O ‘-(9 <br /> IUN . <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 All Information RECEIVED ,S d rn e <br /> Property Owner's Name [� Parcel N <br /> A C/i Properti`es L L c MAR 13 294 O8'CV 6,13- .S Ale -o <br /> Property Owner's Mailing Address Property Location <br /> 7 361 1✓0-r 1 1,-1 0>^,ve_ Public Health MDC Govt.Lot <br /> City,State Zip Code Health <br /> Si 1/4, ‘5(4.., 'h, Section Li <br /> nct-rt e tl 1- 5 35-',7--`7 r, (circle one) <br /> T p N; R EorW <br /> H.Type of Building(check all that apply) Lot 4 <br /> ®I or 2 Family Dwelling-Number of Bedrooms _. Subdivision Name <br /> Z/ Block 4 <br /> ®Public/Commercial-Describe Use OPTIC es•2 s Cm pl o yse.s Did'./Al'n 4 V ❑ City of <br /> 3 pop �/'a,w�s Ll42. No tY <br /> ❑State Owned-Describe Use ember J ❑ Village of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> �CZ_U�t �Townof .Spi'r7 treId <br /> A. fil 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 /> Des n Flow(gpd) DesignSoill Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Y iy. -CC 1 Zr ty p4— V /5'0 0 (.4 —0 0d 3,S <br /> VI.Tank Info Capacity in Total II of Manufacturer <br /> Gallons Gallons Units u o a <br /> New Tanks Existing Tanks � 8 ta u 1 id <br /> aU in , ti w V 4 <br /> SeptiQ_or(folding Tank /6 5 0 L- /6�� r Ole t-e K <br /> G� <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) Plu .er s• _,,;,•re MP/MPRS Number <br /> STEVEN R. CROSBY j�� – ? 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> 7361 DARLIN DRIVE, DANE, WI 53529 — <br /> II.County/Department Use Only <br /> VV.,, / <br /> Approved ❑ Disapproved Permit Fee a Date[slued [ssuin/• � ��. <br /> ❑ Owner Given Reason for Denial &/SY 3 /6 / ��' •�i <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 c 11 Inches in size <br /> SBD-6398(R. 1 1/1 I) <br />