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��� County <br /> \ Safety and Buildings Division <br /> /2C.,fie 1 Th <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)LJ <br /> l f3 )1 Madison,WI 53707-7162 <br /> a� <br /> AFk_.� :J �� 5`CO221 <br /> �on�L / <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. <br /> L Application Information—Please Print All Information <br /> y/ {o r (�„ f Al Property Owner's Name Parcel# 666 %— <br /> /34- 7,5-C70-4„ <br /> fli CO 5 tor? me ,�d i^m L L 4-�15 c,46 I %7'e a -6 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 6-7 -' L Th "?a d/` W i 1 I /?J Govt.Lot <br /> City,State <br /> Zip Code Phone Number I <br /> oat ( 5-35-2 - t—'/<, 5 t, '/<, Section c' ' <br /> (0-55 r W i. r T (circi one) <br /> H.Type of Building(check all that apply) Lot# N, R W <br /> ig1 or 2 Family Dwelling—Number of Bedrooms y Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ii State Owned—Describe Use CSM Number ❑Village of <br /> j V P P c 7 g Town of fr, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> • <br /> A. VI-New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only tel Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.ofsuitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> L` © V `—( lS owl <br /> Capacity Sail X03,5 ((t y.$ jUS;y <br /> VI.Tank Info C <br /> aP ty in Total #of Manufacturer <br /> Gallons Gallons Units c <br /> New Tanks Existing Tanks U "' —° <br /> a. U v� 4,7, C72 L.c F. <br /> Septic or Holding Tank . <br /> C2Y4 /A-Pet / rYleaA t7- . <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume ' ponsibility for i don of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) • Plum. s ign j e MP/MPRS Number 1 <br /> STEVEN R. CROSBY 227009 <br /> 1 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII. County/Department Use Only <br /> KApproved ❑ Disapproved Permit Fee Date Issued Issuing A ignature <br /> ❑ Owner Given Reason for Denial $,1 09.- 7 o- / 5- X j ( -/L <br /> IX.Conditions of Approval/Reasons for Disapproval c/�%%% (/ `�� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size <br /> 3BD-6398(R 11/11) <br />