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• —'x �� RECEIVEl County <br /> ,.. and Bupdmgs Division �gy j� <br /> +fit s, S o o B 10x01 w.Wehrfipton Aver„P.O.Boot 7182 Sant a�y Permit xnmar(m be tilled in CO.�r <br /> ��� l apS. /� Haiti M� Ma�aon,WI 63707-r162 //�� <br /> � Ervtrorurt tl lth �' GV � �Z� <br /> Sanitary Per iii Application State Transaction Walther <br /> In eccordanvc with SPS 38321(2)„WIs.Adm.Cade,submission of this fame to the rpprupriste go emeteetel unit <br /> is roquired prior to obtaining a senlbsy pormll Notes Application 8trnn for state-owned POWYS am submitted to Project Address(if different than mailing address) <br /> the Department of Safoty and Professional Servies. Personal Information you provide nay bo used for secondary <br /> Purposes inmate=with the Privacy Law,s.15.04(1)(m).Slats. <br /> L Application Information-Please Print Ail Information beCr- C r'e t X Run <br /> Property Owner's Name Pared P <br /> r{.rvraS. /Oa 4- Ca 11116;••-• 08U- /7d- $S14—O <br /> Property Owner's Moiling Address Property Location <br /> SJS C/As`Jcsoa RA Govt.Lot <br /> City,State Zip Cade Phone Number /t/ i., M of Si,Section 17 <br /> 44f.1)1, l/ Lt).� I 55 531 T $ N; •P. • •w <br /> U.Type of Building(check all that apply) 'Lott <br /> el-1 or 2 Featly DwrlUpg-Number of Bedrooms Y ) Subdivision Name <br /> Block P <br /> ❑PabiWCommerold-Describe Use ❑Clrya[ <br /> ❑Stela Owned-Describe Use CSM Number ❑Village of <br /> 11.7 1 Alma of " prek rc£. <br /> M.Type of Permits (Check only one box on tine A.Complete line 13 if applicable) <br /> A. ose System ❑ReplsoanmtSytkm ❑Tramens/HoldtngTask <br /> BeasanadOaly a Other ModltiatloatoF•t�f�System CesplaW <br /> B. ❑Prank Renewal ❑Permit Revision ❑Change of Phanba ❑Permit Tanks to New list ou Permit Nrmberlad Deco lamed <br /> Barre Expiation I Owns <br /> IV.Type of POWYS System/Component/Device:(Check all that app yl) <br /> r J1Non-Pmaurlaed be-Qemed ❑Pressurized Incrrauud ❑At-Grade ❑Mgaad 424 in.of aaasbie sou ❑Mound<24 in.of suitable soil <br /> ❑Holding Tack ❑Other Dispersal Component(arplalm) ❑Pretreatment Device(explain) <br /> V.DlaperaalfrreahaeatArea Information: <br /> Design Plow(bpd) Desl*n Soli APplkdtmt/ 0 -Dispersal Area Required(st) rkpasel Area PropaadV) System Elevation <br /> (cob Q, /7c) <br /> / /v 942• 9 1•3 1va..3.— <br /> VL Tank Info Capadtyle Total it of Memr&durar <br /> Odlom Gallons Units q qt g <br /> Naw Dab aa6tlaa Taste a a, O p+ 1 If$ i <br /> 6 07 w h .O a. <br /> - Talk 6 __ =Li It111_'t.7 i� <br /> Dodos Clamber. ,yes. -- . •��____ <br /> VIL Baspans(b[Iity Statement 4 Km aadeeslgned,assume rapeedbUl4 far lmWlaHon of the POW1S shown on the attached plans <br /> Plambars Name(Pd t) MEYMPRSNumber , <br /> } <br /> STEVEN R.CROSBY 227009 608-849-8771 <br /> Plumber's Address(Sheet,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE,WI 53529 <br /> f <br /> VIII.County/Department Use Only ��/ <br /> Pamit Fee Date bend"(Approved ❑Disproved y.1l / i°1'-'20(.51 /4 /' •!�Y ' <br /> ❑Owner olven Reaom Po[Dabd r,J <br /> DL Condltions of Approval/Reasons for Diwpproval <br /> Attila to eemplw pew For Ms gibe and submit to rho Goat oety cm paper wit=Ibis ate all hakes hi do <br /> . <br /> SBD-6398(R.it/ti) <br />