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:'`�e�'�ar1:T County <br /> . 49,r:. <br /> ,' '\,\ a�(� Safety.and Buildings Division 1� <br /> ' 4 201 W.Washington Ave., P.O.Box 7162 ( by <br /> j, $'` r? � '0 9 Sanit Permit Number(to be filled in b Co.) ' <br /> ,\ .: P. , „,/ �� 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. r7 <br /> I. Application Information—Please Print All Information C 4f)4 t ts,rzs S.� <br /> Property Owner's Name Parcel# <br /> tij a i 4 ti R.,I— .aMsitrv� tkA—. n_cL 4-4;6//- 193- cl>yy--c, <br /> Property Owner's Mailing Address Property Location <br /> ?' 43 L'p{ )/0 Govt.Lot <br /> City,State Zip Code Phone Number lit 1� $ b, Section I <br /> qq 4.5*J o/Z ?r4< 4`'s tA)-z 5-3 G✓ i CS J2ircl�one) <br /> II.Type of Building(check all that apply) L ot T N; R_—�" J W <br /> or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block , i �� 74 rk.e.r IS P d LL <br /> ❑Public/Commercial—Describe'RECEIVED <br /> ❑City of <br /> ❑State Owned—Describe Use CS/v1 Number ❑ Village of <br /> JUN $ 42819 4" own of Zr,ax-4, 1 <br /> III.Type of Permit: (Check only oiP&W MAA kket 4C Complete line B if applicable) <br /> A. EYnvironmerltal1- aith <br /> ,�' ew System ❑ Replacement System U 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) t/ <br /> ❑Non-Pressurized In-Ground ❑ Pressurized En-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ■ ,and<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(sf) System Elevation <br /> GOL c.4 61•4%, Jabs 13g ¢ l C6 J /1.�b /� rs �6�`� ,o- <br /> i17 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units g <br /> New Tanks Existing Tanks 7-1 <br /> New <br /> g Li'vr . rn u.0 0. <br /> Septic or Holding Tank n S r 1,4, ( fge.-Cta _ <br /> Dosing Chamber CSIOL.:- apb L. ■L <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 <br /> STEVEN R. CROSBY �i A 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 - , <br /> / <br /> VI I.County/Department Use Only <br /> pproved ❑ Disapproved Permit Fee Date[s ued [ssu' Aggpi,Sjgnatt :—_ j <br /> ❑Owner Given Reason for Denial e s/' /s )s `G <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 t l Inches in size <br /> SBD-6398(R. I I/11) <br />