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I <br /> ,r �K{i-7-7"Jr" "' County . <br /> /'41-'' • , \ bl i 'Safety and Buildings Division <br /> ct n/ <br /> rt ' ;� � sii 201 W'WashIi1gton Ave„ P.O,Box 7182 Sanitary Permit Number(to be filled In by Co.) — <br /> L Madison,WI 53707-7162 <br /> 1� 3:20\ M ao.590i <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 Satbty and Professional Service. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.13.04(i)(m),State. <br /> I. Application Information-Please Print All Information 9 7 Y ti(£A. 1 Rd <br /> Property Owner's Name Parcel S <br /> f',r C.•%. /C Ki,,e,h \TT b $1)7 - _Col- 5,1`ac,-.3 <br /> Property Owner's Mailing Address Property Location <br /> 1 o "1( 94.4 Govt Lot <br /> City,State Zip Code �/ Phone Number $e- y4, 444 r/4, Section 3e _ <br /> lef 1/.174 , � 1 N. R (ci •. ono) <br /> II,Type of Building(check all that apply) t Lot 1� � W <br /> G -or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block S <br /> ❑Publlo/Commereial-Describe Use City of <br /> ❑State Owned Describe Use CSM Number ❑Village of <br /> — own of, . ` _r_�_.3 ,_-, <br /> III Type of Permit:(Check only one box on line A. Complete line B If applicable) <br /> A. ❑Now System ' -Raplacement System Cl Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> . <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to Now List Previous Permit Number and Date Issued <br /> Be ore Expiration Owner <br /> IV,Type of POWTS System/Component/Device: (Check sill that apply) <br /> ❑Non-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Gradeound>24 in.of suitable soil ❑Mound<24 In.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) f ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Informations i <br /> Design Flow(gpd) Design Soil Application Rate( dst) Dispersal Area Required(st) Dispersal Area Proposed(4 System Elevation <br /> p <br /> VI.Tank Info Cartel In Total r 11 of Manuf etu r <br /> Gallons Gallons Units A <br /> New Tanks Mating Tanks A l <br /> Septic as.kiaiiiikarTank 84,0 !L d Mllfa + .s ..✓ -° <br /> Dosing Chamber gyp ......i l . _.-r..... �+ <br /> — <br /> VII,Res'onsibliit. Statement- I the aaderei ned,assume res,onsiblll for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) . P ulnb., n re a._..__ MP/MPRS gumbo* I i <br /> STEVEN It. CROSBY �� — 227009 608-849-8771 <br /> Pium ci s Ad rose($treat,C ty,Slats,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VI L ount De tmant Ilse On. <br /> Approved ❑Disapproved Permit Pee Data issued issuln A t gntuuro <br /> 12-2- <br /> d Owner Given Reason for Dailai 1,�2.:�t� r /�9�4 \Ihrr7�N1 <br /> IX.Conditions of Approval/Reaso s for boa rovai 0 < � fF�►7er._ rqerit, <br /> -->.Mawo sy; H', ft 7'E ,fet# 0.14 ,4 (s- !o ' P-4//r fh'E / 'f T 6'G ./?.cc M <br /> 7M ((L 6/0‹...-140\e/ ./.0(L 4.Cft k- G? .A4 __ Ct.,44,c 7>ci F c. <br /> Attach to complete plans for the system and submit to the County only on paper not Ism than 8 1/2 x 1.1 Inches In size . <br /> SBD.6398(R. I1/I 1) <br />