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/ci,C7sE r\ County <br /> '� ,, Safet g <br /> r• \:•.;71.., 201 W.Washington lAve. P.O.Box 7162 � 1 <br /> r (�$ Washington Sanitary Permit Number(to be filled in by Co.) <br /> i"t I"! Madison,WI 53707-7162 <br /> ,.,t _es ' (1-10 i 5- y 3 <br /> �fvs,or�/ 1 , <br /> SState Transaction Number <br /> Sanitary Permit Application - <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit `; i ; <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state owned l A ffs 4re2utnpAn to Piojegt Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information yoit°{�rbvide may be used for secondary ; L,/! <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. I <br /> _L Application Information—Please Print All Information ;_ _ = 1 ° Uf `r'O2/e, It <br /> Property wner's Name /� )) F _.' Parcel# <br /> Property C[E��n S U90'i - CS61 I . 9,/e S- 0 <br /> Property Owner's vtailing`Address Property Location <br /> 75 5 .✓ EJ LS l2 b V-e (k r) Govt Lot <br /> City,State j ip Code Phone Number 3'A) 'A, NE /, Section <br /> J /xre W � 3 s�i 1 (clr,ne) <br /> II.Type of Building(check all that appl <br /> Lot# T i N; R ` er W <br /> Tor 2 Family Dwelling—Number of Bedro'ms 11 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 1 395 3 foTownof /) e..4/ 9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .PFew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Vv Other Modification to E.cistin,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 /> oii ressurized.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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 4Pe3 o . 't I S2:5,P. 1sea '3,3-- ` i.s ' 4).z.s' <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d o z• <br /> New Tanks Existing Tanks d ` <br /> y to o q Q <br /> q /1/7e a U in y rn is 3 i= <br /> Septic or Holding Tank 1 d e'/ r a N L. I A �_ . <br /> Dosing Chamber �n <br /> VII.Responsibility Statement- [,the undersigned,assume responsibility for installs•', .'the POWTS shown on the attached plans. <br /> Plumber's Name(Print) ii MP/Iv1PRS Number <br /> STEVEN R CROSBY �f ���.� 227009 :49-8771 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 7361 DARLIN DRIVE, DANE, WI 53529 �. <br /> VIII,County/Department Use Only <br /> ❑ Disapproved <br /> Permit Fee Date Issued uing Signature j� <br /> ❑ Owner Given Reason for Denial $` �'—� —/S "� ■ r� �• <br /> IX.Conditions of Approval/Reasons for Disapproval i ._ y�^V <br /> /.. 0 / <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a Ii inches in size <br /> SBD-6398(R. Il/1l) <br />