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,evnrt k.„1„ County <br /> °� q° Safet <br /> /r \ y and Buildings Division �4•? <br /> 201 W.Wa$hington Ave., P.O.Box 7162 �� <br /> ra >ia•6 -'� Sanitary Permit Number(to be filled in by Co,) <br /> f,k, ='s ;$,.,i Madison,WI 53707-7162 <br /> 1' .,t , ;;r ) 3-2,m/C - oOZ(c <br /> Sanitary Permit Application State Transaction Number <br /> En 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 /fit• <br /> v� /9 <br /> Pr..: Owner's Name <br /> Parcel# <br /> i / <br /> rG, ,15 a/Ia 3>:/L ZII AI' Z)6,, - 473 -- B4).t-2) <br /> Property Owner's Mailing Address Property Location <br /> A/ 5 of V a A I)' R ?KZ& Govt.Lot <br /> City,State Zip Code Phone Number <br /> q ''� 11 4/Q1 4, ✓�.t I y., Section <br /> b fd. 0 r.>4. 1.4 � 'S3ay T v N, R / ►(circleone) <br /> H.Type o ilding(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms , Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> to 993 ATownof 71/C1-/)..4; <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> / ItTNew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0.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 /> i.I •on-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 /> Design Flow(pd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(so System Elevation <br /> IA •Z7' 6,4/ '�i-5—b ) 1/' r 51 a g 1),.;il Y,11 ii y s.1V.tr <br /> VI.Tank Info Capacity in Total #of Manufacturer t <br /> Gallons Gallons Units <br /> ^� <br /> , <br /> U <br /> New Tanks Existing Tanks .. .. <br /> 0o G <br /> a U Cl h 0 0 a. <br /> 'optic or..'ding Tank <br /> laaiib 1ae/A I 4/e-s3 de7 . <br /> Dosing Chamber $b 0 t oe5 1 !i <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's Si ature MP/MPRS Number t <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.Coun /De I artment Use OnI I A <br /> Nt4 Approved ❑ Disapproved <br /> Permit Fee Date Issued lssuin _ �� <br /> ❑ Owner Given Reason for Denial gv_____ 1 <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> / <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 n LI inches In size <br /> ■ <br /> SBD-6398(R. 1 1/11) <br />