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‘:;vi..-Al6r f> County <br /> r!;< _ A\ Safety and Buildings Division '� <br /> Al- <br /> ill }} <br /> S 1 s`` <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit ID/4 <br /> tuber(to be filled in by Co.) <br /> i t . Madison,WI 53707-7162 <br /> ,,,. %% 3 . 2a (5^ 0 27 d <br /> ��?IONL� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of thi Raw to,• - -•tal unit <br /> is required prior to obtaining a sanitary permit. Note:Application font ,fir t owi .P . . ''tied to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal informati n r oata e s-. • -condary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. j � �� <br /> I. Application Information—Please Print All Information AUG 2.5 2015 t.//6 /' /^ <br /> Property Owner's Nam w Parcel# <br /> lam. / K v k l/it Public Health MDC <br /> Erwiropmeatal Health Q <br /> `?0 7_ l "l" b p _i) <br /> Property Owner's Mailing Address Property Location <br /> 46 5- 4104, it / tP0`L 0-/- Govt.Lot <br /> City,State Zi• •. Phone Number <br /> K C' /)( �^ Ai� Y., �Ll)'/., Section 0!it ', g3 <br /> T /crrcleone) <br /> H.Type of Building(die all that apply) Lot# <br /> N; R EorW <br /> ail—Or 2 Family Dwelling—Number of Bedrooms , t2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use INI <br /> ❑ City of <br /> W CSM Number ❑ Village of <br /> ❑State Owned—Describe Use <br /> 'own of'rt l9z 7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 4 New 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 /> ,Non-Pressurized In-Ground ❑ Pressurized[n-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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> teO b D, (o.`l._ zi. 53' /04zp 98.0 '"..S.- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> 2 o u c, <br /> New Tanks Existing Tanks v c u = u w` ' <br /> 6.o. U co H cn ii 0 a, <br /> Septic or Holding Tank ` 08(47 /,,� u� I NecidQ <br /> Dosing Chamber / ,� 05z) / <br /> lJ <br /> VII. Responsibility Statement- I,the undersigned, ssu responsibility for installatio of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) limber' re r MP/MPRS Number <br /> STEVEN R. CROSBY 227009 <br /> ,44• /-40„... ._. 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 Fee Date Issued Issuing nt Signature <br /> 4'3' -- 8-26_Is , �D -C- <br /> ❑Owner Given Reason for Denial ..�� <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 In z 11 inches in size <br /> SBD-6398(R. l I/I l) <br />