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i <br /> -i%arirs vr� County <br /> /„? s \ -Safety and Buildings Division „ <br /> U ' <br /> (,r 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) I I <br /> Sp !� Madison,WI 53707-7162 <br /> \�� IT 13- U C 9G\ 1 <br /> Sanitary Permit Application State Transaction Number i <br /> 7 <br /> In accordance with SPS 3$3.21(2),Wis.Adm.Code,submission of is form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application f rms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal inf ation you provide may be used for secondary <br /> purposes in accordance with the Privacy Laws. 15.04(£Xm),Stets. <br /> I. Application Information—Please Print MI Informatio ]G 1 c is Co ,b coo d(di <br /> Property Owner's Name Parcel H <br /> ---1:1”)an d'" 63-PfA ale/trsn .'ru.Id 6 fro g — /6 / q0 'f C,._0 <br /> Property Owner's Mailing Address Property Location <br /> ?Y 5 r K't c k et boo g el mart.Lot <br /> City,State ip ..e Phone Number F.:.. i /6 <br /> S Lv V4, ill /,, Section <br /> W&t i a k e e (AV) 5-35 7 (circle one) <br /> II.Type of Building(check all apply) Lot# T $ N; R. �'i E or W <br /> 62 i or 2 Family Dwelling—Numbe of Bedrooms t Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe 1I "gill=imi 2 Ili <br /> ❑City of <br /> ❑State Owned—Describe Use ;MAY 0 3 7016 CSM Number ❑Village of ' <br /> / x/.247 Re Town of 5',1rlo. x401 <br /> is$a th mix <br /> III.Type of Permit: (Check onitt�o i b M)4 ►lete line B if applicable) <br /> Q New System d. ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0.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 ❑Mound X24 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(,pdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> -/U / _ . / e/ ,r //g 5 '/ j/'; f 43,0 - q2.0 ---. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 1 o g <br /> New Tanks Existing Tanks it o u es <br /> aU in q Ti", is;Q a <br /> Soptic org Tank <br /> •/00 0 # /G°OC) f Aa'ct 0# f j a" <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumhe' r _ MP/MPRS Number <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 /> Pe 't F • Date Es ■ Essuing ignature <br /> ❑Approved ❑Disapproved <br /> ❑ Owner Given Reason for Denial $ ''MI . ' a s i t� � /' ,,,5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> . <br /> Attach to complete plans for the system aid submit to the County only on paper not less than 8 1/2 t 11 inches in size i <br />