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„,.v>-----,?'\ County <br /> s`; S `;^, Safety and Buildings Division /Vr' <br /> i_, D 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> p . )-) Madison,WI 53707-7162 <br /> \r s - i3- 2n1(0- ac�o83 <br /> r..FEtSIO„,, <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 be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. S g/*f/5 r.2) <br /> I. Application Information—Please Print All Information /! G <br /> Property Owner's Name <br /> Parcel# <br /> 2 ' gG n Z c_11 F e 425c.....425c..... ... RECEIVED 05 1 - i V - 9-5-60 - 7 <br /> Property Own er's Mailing Address <br /> Property Location <br /> / APR 2 2101G <br /> V <br /> 1p. / 9 �I it t 16 Ave Govt.Lot ` <br /> � <br /> City State Zip Code PhoP9til"F lth MDC .5' '/., /, Section f i <br /> h1, a-2,- 5�� 8 9 Environmental Health T N; R t circ one) <br /> �j c W <br /> II.Type of Building(check all that apply) Lot# <br /> V or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> (Town of A i h ,-d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 13 Replacement System JAI Treatment/Holding Tank Replacement Only Of 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 -51 777- (3SAf 2L 5:-04-09S- <br /> Iv.Type of POWTS System/Component/Device: (Check all that apply) Z7� <br /> ikNon-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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> .Ut') r) ' 7 V a q b 3 4 `-- <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units a o'O <br /> New Tanks Existing Tanks 2 o u 2 ,a <br /> a. U in H rn ii U 0. <br /> Septic oc.Welding Tank /0.7'd ”- ID.,17. I 4e fC.4 e _ <br /> Dosing Chamber lx?C,d k 6a <br /> VII.Responsibility Statement- I,the undersigned,assym: ••s onsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pt }tiler's Si:i'tut.: Ari MP/MPRS Number <br /> STEVEN R. CROSBY ,�' � i 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 /> pproved ❑ Disapproved Permit Fee Date Issued [ssuin gen Sig a 0. <br /> ❑ Owner Given Reason for Denial 5S 7 II-2.2--20/6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> —4. e t VI* (1'f S`f(1)417r r iet.0 r7AU 7 ����f X�i� z7- ?6r <br /> j ,Ai- ? i S' - te '4 Cc w/ 7 P .��1�- <br /> �� .Attach to complete plans for the system and submit to the County only on paper not less than 8 in x I I inches in size <br /> SBD-6398(R. 11/1 I) <br />