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",i,an,i�• <br /> r � ' F EC E TvE rp Safety and Buildings Division L)4 M' <br /> ;, ..445 V L,Jz <br /> 01 W.Washington Ave., P.O. Box 7162 o <br /> (�% �D$ .',i:::i � 9 Sanitary Permit Number(to be filled in by Co.) <br /> �1 `� Madison,WI 53707-7162 <br /> ' �`S 46 7016 <br /> \:',. '% APR l3 -?AD( 6�-00o80 <br /> �`Fvrusx,� f ublirtleattit Mu <br /> E State Transaction Number <br /> Ell rii't fl s:it- A Application <br /> En 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 MI Information t';'i •-; ,,, ,. <br /> Property Owner's Name '.a 0:1,--,;iii---7,,,,..; Parcel# " <br /> be ..P1,'� 13 go" o '1/qr -- 61 Of7//) 3 Y- 2a - 0l <br /> Property Owner's Mailing Address / Property Location <br /> /57 0 _ / �f° .7/` Cua7 Govt.Lot <br /> City,State J- 3 Zip code? Phone Number (�y, r5 '4, Section <br /> I�.�G_/ /1 I,)z / / (circ one)II.6T eoof/Building checkaallthata I Lot T -N; R //a W <br /> Type Building apply) 3 - <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> f� <br /> _ <br /> Block# U h'CG�r` L 1'�j <br /> ❑Public/Commercial-Describe Use - <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Town of v/`/Ce- <br /> _ 1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ril Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> a-Ron-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 6 -) 6 3■ t aGLI ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design��(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(se) Dispersal Area Proposed(sf) System Elevation ''-> 'D/ <br /> (9 G&( //r-3?T-. >/ Yv 912417), 3/9t,D ill( , <br /> VI.Tank Info t Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o 'a o <br /> New Tanks Existing Tanks 'y 2 u 2 B. 0 <br /> _ ii a U n H to il.V <br /> Septic or-13o46iog Tank / ,STO — /D S-6 y Retio/ <br /> Dosing Chamber <br /> rP/ , j <br /> C f <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa ure MP/MPRS Number <br /> STEVEN R. CROSBY C �/ A 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 /> Permit Fee Date Issued Issuing Agent ign e <br /> proved ❑ Disapproved 3 <br /> ❑ Owner Given Reason for Denial g it Y-20-20/6 �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 12 i 11 inches in size <br /> i <br /> SBD-6398(R. I I/l 1) 4 <br /> I <br />