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(1-0 to pv-t 4,1,i -F <br /> i — rr v County <br /> �� —ST\ <br /> it,, , �;., Safety.and Buildings Division ally <br /> rs( , I 201 W.`Washington Ave., P.O.Box 7182 Sanitary Permit Number(to be filled in by Co.) <br /> 1 ���111< P J Madison,WI 53707-7182 <br /> ra }-' _ 13 -20► 5 od38 � <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 bo 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 Hae///0 W /0'd (0-(7604,-4 <br /> Property Owner's Name -Parcel# <br /> 705P ph 0_“..1--a 6.i.oe - o5-4 -6 6 78-0 <br /> Property Owner's Mailing Address Property Location <br /> Ce t ?0 C."I N i'Ii.4 e Govt.Lot <br /> City,State ./ J Zip Code Phone Number , , 5-- <br /> N�GG /,, 5 E /., Section <br /> //L[n e i u r 5-”----q T & N; R (circle on one) <br /> II.Type of Building(check all that apply) Lot# <br /> El I or 2 Family Dwelling-Number of Bedrooms Li 0 Subdivision Name p <br /> Block# - t�CLrrrrpny Tdne <br /> ❑Public/Commercial-Describe Use / <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> ®Town of lJA{/ J rref AIP1d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' El.New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only til 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 /> grNon-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(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 60p / 6 /MO /.2.0(.• (l,F,c) 47q, r 9 i.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .gg G <br /> New Tanks - Existing Tanks k "t;8 P i 1 <br /> aU h rn ii.t., 0. <br /> Septic or Holding Tank /;2.0,..6 <br /> / S-4 / Meld(J,n <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibili for Install: -,n of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber s atu MP/MPRS Number ■ <br /> STEVEN R. CROSBY Ai/ \ `- 227009 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 /> Td <br /> Approved ❑ Disapproved <br /> Permit }Fete Date Issued Is! 7 ",uin t Signature <br /> ❑Owner Given Reason for Denial $ 7 0 ! r /2^ /5" /l� C <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 5 11 inches in size <br /> SBD-6398(R. 11/1l) <br />