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coc+!ari!gyy e <br /> �,./ ter\ `�(u County <br /> j/?% \ Safety and Buildings Division 'Ddtn> <br /> (' ,S P )1 i t 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co <br /> ,� Madison,WI 53707-7162 <br /> '' 0 3-Zp1S-002gQ <br /> 6, <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 /> I. Application Information—Please Print All Information 4/p r lC� .l 1?d <br /> Pro y Owner's Name <br /> Parcel# <br /> a01 2 J)eiY�-f��AGC�•z� �t 0 91/ - 1 9'Y ysy6.--z, <br /> Property Owner's Mailing Address Property Location <br /> .-/e:, 7 C..ic'c 5j-)r ' 5 (I�e�( Govt.Lot <br /> City,State r ! Zip Code Phone Number <br /> Pe Yep re s2 0 -,r 3 iS-3-� g Gc7 '/., .3 �C /., Section t 9 <br /> Type of Building T 9 N; R E or W <br /> II.T <br /> yp g(check all that apply) Lot# <br /> ( or 2 Family Dwelling—Number of Bedrooms _ Subdivision Name f� L <br /> Block# Le--,holeWS Vdd;a ( <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> fl State Owned—Describe Use CSM Number 0 Village of <br /> 91- 5-nof ( l.$fp ) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ■Ce ew System ❑ Replacement System ❑Treatment/Holdin Replacement Only g Tank lacement p y tx3 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 ap sly) J <br /> ❑Non-Pressurized[n-Ground ❑Pressurized[n-Ground ❑At-Grade i■ .Ind>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 /> Y�� b, Cl.IS 7P (z'tsl,,) loo s� 6 ,o ' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> H New Tanks Existing Tanks rn H vt w0 a. <br /> Septic oe4[etefing Tank I 0 t5� V, jd-,� t <br /> Dosing Chamber )) ��� �' <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe' ' tur MP/MPRS Number <br /> STEVEN R. CROSBY 2270000 9 <br /> 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 /> pproved ❑ Disapproved <br /> $Permit Fee Date Issued [ssuin gent S' natur <br /> ❑Owner Given Reason for Denial ����� ! ����� /4-e1/1"3" <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pg 7' A°wyD r-i f04. r(74- /few A-/€ 01 (s- P--CE 7 ,r ,Ac <br /> F.gott,- $ ? cwintO,4c?c,/}; .C. t'G 6j(C4/ 9-�.0 r �"1% fr 7 Cc444-. l?49k <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tlz a I I inches in size <br /> SBD-6398(R. l NI) <br />