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, dt,taflµ� rr County <br /> /���'y ���r\ �� [I '�� l t afety and Buildings Division co�cn P` <br /> (sl S' ''/ "`' !-"`"`--°-` -"2 , .Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t„+ t. e 1 /i Madison,WI 53707-7162 <br /> �.,-' ',:.'''.,'S. ,' ' r <br /> \ q- ��;i j 4 MAY 1 9 2015 13 -_ZO14 - oO(`- 4 <br /> ION• <br /> to i! �! Ap lication State Transaction Number <br /> In accordance with S S 383.2 );'•1 is Adm' ode, . ission o this form to the appropriate governmental unit <br /> is required prior to of tairring-asanitary permit. Note:A.. '.. - .rms 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 Pr' t All Information /1/j rs �rt ve <br /> Property Owner's Name r' <br /> C.�4i'►'r Lb A N Al�� tc U['ti' Parcel# <br /> Ye 04 1 hrech'f w.,..) 0fel0 - a9-2 - 001-1S- 0 <br /> 2k' ePro perty Owner's Mailing Address Property Location <br /> /' eo,Isd' ) 3lv? $Q 060/e_ Orook 1-c a:1 Govt.Lot <br /> City,State Zip Code Phone Number , <br /> /1/E 'A, !Vw b, Section <br /> 5(.4 o era■r1 Z. LV ._ 35 9 a (circle one) <br /> II.Type of Building(check all that apply) Lot 4 <br /> T N; R /0 E or W <br /> 23,1 or 2 Family Dwelling—Number of Bedrooms 5 ✓- Subdivision Name <br /> Block# 6 e r Ind' /5 1rto4/ <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> -Town of 1c3l,t/'IC e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ®.New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only t31 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 igi 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(sf) Dispersal Area Pro ose�sf) System Elevation <br /> 7�0 -' -7 ;�)2-t) -.7 0 i 5 /G A,s-I <br /> VI.Tank Info Capacity in Total #of NI ufac�) <br /> ap ty r <br /> Gallons Gallons Units ° 0 v V <br /> New Tanks Existing Tanks ' 0 u 7 Q <br /> a`U in H C7 0. <br /> Septic or Holding Tank /6 - /6 5-0 I /ale k-.l.c a <br /> Dosing Chamber <br /> You /1'0 V l /hca1-e Pe <br /> VII.Responsibility Statement- I,the undersigned,ass y6nrespo •"ility for installa•+ I, he POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's 7 / MP/MPRS Number , <br /> STEVEN R. CROSBY 227009 <br /> ..� 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) 111�° <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> '' pproved ❑ Disapproved Permit Fee Date Issued ssuing Signature <br /> ❑ Owner Given Reason for Denial 1 tif� 5"Za /.5' /di 4° � �^'o <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 to i l l inches in size <br /> SBD-6398(R. 1 I/l l) <br />