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OgrARit y County <br /> '- . �r� Safety and Buildings Division Coun Do�E <br /> I . S 1) p a 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(robe filled in by Co.) <br /> ',L\ <y le, 1 f Madison,WI 53707-7162 tiii\\, `r_.= <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),Scats. (r <br /> I. Application Information-Please Print All Information RECEIVED !'r4na„ 'PQ, <br /> Parcel# <br /> Prope Owner's Name <br /> it k6 ik(4 b 61a rS A4 24 AC)'S ky p( 2 61015 e 0 c5.`U 51�OP i/.j--® <br /> Property Owner's Mailing Address / Property Location <br /> 1 133 1' 5- c.O/, J Public Health MDC Go Lot <br /> City,State Q Zip Code l�Qi °l Health <br /> �} /., St, /., Section <br /> a:V-7)A i f� ill 10i 4f / T N; R rs c�E or <br /> IL Type of Building(check all that apply) Lot# / �/ <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 116 1 6, Subdivision Name <br /> ,j <br /> Block# — fcr .pl P.,z <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 4-Town of N <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only W <br /> Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber El 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade u-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/Treatm ent Area Information: <br /> Design Flow(pd) Design Soil Application Rate( t) Dis sal Area Required(sa l¢1 Cptisp Area posed(sf) System Elevation <br /> (, , 0,4 ( (1 [ a (//- 4,. 0 ?sty <br /> VI.Tank Info Cap ity in Total #of M cturer <br /> Gallons Gallons Units c e C) <br /> New ranks Existing Tanks w e u , 'u u 2 A <br /> E 0 rn � yr w(7 a <br /> Septic or Holding Tank 10)FO' i>e 4 1 M e fp_`I C <br /> Dosing Chamber (056 4 51, 1 / f 4 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb•' 'y ature MP/MPRS Number t <br /> STEVEN R. CROSBY <br /> / 227009 608-849-8771 <br /> 974,107% <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> jApproved ❑ Disapproved Permit Fee/ Date Issued Iq to t SignatuXre (�/ <br /> ❑ Owner Given Reason for Denial y2/./O 9-i !'� ` v <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 II inches in size <br /> SBD-6398(R. 11/1l) <br />