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Ana' — <br /> :j: r-... / County <br /> �,�; �� Safety and.Buildings Division Dad r (N• <br /> (s( $. .• f, 1". S 201 W.Washington Ave., P.O. Box 7162 Sanitary PermitNumber(to be filled in byCo.)•<• -. . Madison,WI 53707-7162 <br /> \i t' ,•..$' 4^l <br /> Sanitary Permit App1'„. '+ • State Transaction Number <br /> In accordance with SPS 383.21 2,-Wis.Adm.Code,submission of this • ��•} . ro at ! e�n I unit <br /> O ate ttEPi"i' <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owne are ttted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you prov �nlgy be„UU ptgd for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ��uu oo L <br /> I. Application Information-Please Print All Information <br /> Pr erty Owner's Name Public Health MD <br /> t: Parcel# ” <br /> WC) ii. Environmental Health 031 -/i1. 3 - 8 4'36 3 <br /> Property Owner's Mailing Address Property Location <br /> S" 3 04' K ktr Govt.Lot <br /> City,State /I ( l ) Zip Code Phone Number ,�I,a} ��• .Su5 y Section <br /> P14,-.54t4 t 4 1 I `"r Z ,9 3,J s, g� bird one) <br /> II.Type of Building(check all that apply) Lot# T V N; R I W <br /> I�}L.or--2 Family Dwelling-Number of Bedrooms 3 ) Subdivision Name <br /> ��ll Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑l Village of <br /> ,,75r1/ Town of Re.(/ I /t 4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 7 0 er Modification to Existing System(explain) <br /> ` LI 0.Ati °a.-+rD JV <br /> B. ❑ Permit Renewal ❑ Permit Revision GI 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 /> 1 .Non-Pressurized In-Ground ❑ Pressurized[n-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(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .gg v c v S <br /> New Tanks Existing Tanks y c u 2 T I <br /> •�� a`O inv ti wv F. <br /> Septic or Holding Tank `OC'e> /re- 7 1 \ A. )M r l <br /> Dosing Chamber 1)12 t9 OP �J// <br /> VII,Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber ' re MP/MPRS Number 1 <br /> STEVEN R. CROSBY 227009 <br /> 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 Date Issued Issuing Agent Signature <br /> ❑ Approved ❑ Disapproved <br /> n r-❑ Owner Given Reason for Denial �e -, / ,/ <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 L l inches in size <br /> SBD-6398(R. 11/l I) <br />