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/r irr,(4 County <br /> �,;<;- ?..- \ Safety.and Buildings Division ��4,S/� , <br /> ! / �, 201 W:'Washirigton Ave.,-P:O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> {= S.p 'r �"� ��� Madison,WI 53707-7162 <br /> ��0s� Y„„fi ecnILI <br /> State Transaction Number <br /> Sanitary Permit Application <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 13'4<-,t- C h G r 7 C.+ <br /> Property Owner's(Name Parcel# <br /> 4 if z S'ef,filie r-5aQ t../6t, ogs 353-$.0 ya -6 <br /> Property Otvntris Mailing Address Property Location <br /> 6 a 7 / -,51/. I Far X L4 4 7/ Govt Lot �� <br /> City,State j Zip Code 7 Phone Number �/V 41 Vs, 54.1 /, Section <br /> 0 1`¢-1 Li "t 'I— ... ._ 'S''r, (circle one) <br /> II.Type of Bililding(check all tlla�pply) `-s, Lot#j T N; R f� E or W <br /> ,1 or 2 Family Dwelling—NumlCr of Bedrooms j j/ Subdivision Name <br /> i Block# <br /> ❑Public/Commercial—Describe <br /> ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned—Describe Use FEB 0 1 20E i �a3� T own of Ve#74"Let, <br /> III.Type of Permit: (Check Qnly90§dieottNANDEL Complete line B if applicable) <br /> - Environmental He - <br /> �New System ❑Replacement System reatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade Wound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(e lain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispyssal Area Required(s Dispersal Area Proposed(sf) System Elevation <br /> /oa 4 4.<4. 1/-6'410 < 0) t C 0$.5 /0 -•ei <br /> VI.Tank Info Capacity Total #of Manufac erilt r <br /> Gallons Gallons Units u o 'fl °_ <br /> New Tanks Existing Tanks w g u a u 13 Ir 03 <br /> ct U iii A 0 iZ C7 a. <br /> Septic or Holding Tank -1 a It. /Wt. p w��it£4,zi� <br /> Dosing Chamber { 45f' Oct 1 l e t7- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for' Ilation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) . Plum r s ga MP/MPRS Number t <br /> STEVEN R. CROSBY -- 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 /> Approved ❑ Disapproved Pe it Fee Date Issued -lime Agent_:,1, <br /> Agent <br /> ❑ Owner Given Reason for Denial A a , i‘.." / ill,41 <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 t/2 x 11 inches in size <br /> SBD-6398(R. 11/11) <br />