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lARTkt�?I County <br /> „:- - �� . Safety and Buildings Division Darte <br /> 201 W.Washin on Ave:,P.O.Box 7162 <br /> $p +' I�� gt Sanitary Permit Number(to be filled in by Co.) <br /> t Madison,WI 53707-7162 <br /> o. <br /> i 13 - 26 k S---002A-1 <br /> ,,..mg <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission oQthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application rms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal inforptation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),State.', <br /> L Application Information-Please Print All InformatioIn Ait'na Pond 7 <br /> Property Owner's Name nn Parcel ti <br /> (NQrr'eA ti R4,re kose <br /> Property Owner's Mailing Address Property roper o 0 io- 312- app - (j <br /> Location <br /> 3r; Oak b iti e (' ti- Govt Lot <br /> City,State 1 Zip Code Phone Number , , y, �� 1/4ti Section 3 1 6 J �' (circle one) <br /> rt 50>t (iU= 7 T N; R ? E or W <br /> Type of Building(check all that apply) Lot 8 <br /> 1 or 2 Family Dwelling-Number of Bedrooms / , Subdivision Name <br /> • <br /> Block# Aafrl.lit, Pone <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of c n <br /> 6 Town of Sprt%r ie.((y <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) 1 J <br /> A" '{g New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only V Other Modification to <br /> 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 /> VNoes-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(gpd) Design Soil Application Rate(gpdut) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 400 `/ /SDO _ /500 /oi.o g4.9 <br /> VL Tank Info Capacity in Total 8 of Manufacturer <br /> Gallons Gallons Units <br /> New Tads Existing Taala ' a d 3 ,� $ <br /> w U in� y a a <br /> Septic or Holding Talc 1 9-G <br /> Dosing /2sf L 1 Alga,P r DC <br /> VIL Responsibility Statement-I.the undersigned,assume re#ponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) . Plumber' ... Number <br /> STEVEN R.CROSBY ��:,� II 227009 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 /> Approved ❑Disapproved Permit Fen Date Issued Lu " n Signature/ (�/ / <br /> ❑Owner Given Reason for Denial S Y V r �— 7"'el--GS— <br /> IX. (%y� Y/ C/�`�v <br /> Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system ar✓d submit to the County only on paper not less than 8 to alt inches in sae <br /> SBD-6398(R.I l/11) <br />