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r �,ei anrhv,„ County <br /> (.. '.• Safety,,pn�I.Buildings Division <br /> ;I.c ; 20i W.Vt/l`shfngton Aye:, P.O.Box 7162 ��,,��� <br /> ' s:� Sanitary Permit Namber(to be filled in by <br /> ,.` :i$ Madison,WI 53707-7162 <br /> J ,N�;;/ ) 3-2Lhc- oat t -- <br /> Sanitary Permit Application State Transaction Number - <br /> In accordance with SPS 38321(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(l)(m),Stets, <br /> I. Application Information-Please Print All Information /dw) `c <br /> Plity Owner's Nam Parcel N <br /> Property Owner's Mailing Address 1,o? Q v ' <br /> Property Location <br /> GT V a A n ct ).7 ?1�4Jy Govt.Lot <br /> City,State Zip Code Phone Number <br /> 4/41'/, 521-/ 'A, Section .7 <br /> be l . A C'� 44). y (circle one) <br /> 1T.Type o Building(checkoff that app Lot N T + N. R I ►� Eor W <br /> ithr or 2 Family Dwelling-Number of Bed m a Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> tel 993 Town of /7/C d//14 <br /> III.Tge•of Permit: (Check only one box on line A. Complete line B If applicable) <br /> // <br /> 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 /> , [ <br /> ::lNon-Pressurized in-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in,of suitable soil I <br /> ❑Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: - <br /> Design Flow(gpd) ' Design it Application Rate(gpdst) I Dispersal aeR-equired(st) Dispersal/Area Proposed(sf) System Elevation <br /> I.Tank 4e:,2, a Capacity in Total N p �r 51 ; I <br /> `!r,i q y,1/1 y.s,.,si,f!"` <br /> Manufacturer ( e <br /> Gallons Gallons Units <br /> Now Tanks Existing Tanks <br /> ni Li O <br /> oo vc <br /> --Soptio er ding Tank )W?6 1,014 1 4/el,,�f) <br /> Dosing Chamber $G a IS'd,. f d�� <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Si elute MP/ivIPRS Number I r <br /> STEVEN R. CROSBY I ..01/ 227009 i <br /> JJJJ r/ �� 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> VIII.Coun /De•artment Use Onl j -a. <br /> `'4.Approved ❑ Disapproved <br /> Permit Foe Date[sued Issufn!. : •.0 Owner Given Reason for Denial -~ <br /> IX.Conditions of Approval/Reasons for Disapproval vim ■ -W =- <br /> puitt,u0 -6,147--;G_AA .sea..._./t-uu---1 - ''•' 1-1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 us c t i incbee In size <br /> SBD-6398(R, 1 l/t 1) <br />