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�r%ear�� �,\ County /` s <br /> 0 <br /> I/3i 4 ��� p s� ' ,' . "1I.3-6.• Division 'b#4-AA".:( D } } 201 W ': P.O. Box 7162 <br /> ! S D - ' !il �1 Sanitary Permit Number(to be filled in by Co.) <br /> 1 Madison,WI 53707-7162 <br /> Y� /, <br /> \', -,,-_-�, RECEIVEQ -�o1 0/0 <br /> Sanitary Permit Application II 77 it. State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the apprd t a te•g6vEt'ttlllental 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 provilielliftylitbAiWildersecondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Environmental Health /� <br /> I. Application Information-Please Print All Information it, e t 3 Dr- <br /> Property Owner's 37 Naa�me :• } /1 Parcel# <br /> /`%2�jY-r'C? rlL� f►1d P‹ Y4Ib tie., ('7rc3 v Ol1' Oc9 - C 1/j r1V5 <br /> Property Ownetttt.'s Mailing Address / Property Location <br /> ( s /T e /9.17,714 �,-S'� t>d Govt.Lot <br /> City,State ! Zip Code Phone Number /Y t v. /y/LL/ 1/4, Section <br /> Wet lJriet kg t lr . L3zs9 7 (circle one) <br /> H.Type of Building(check all that apply) Lot# T N; R E or w <br /> e of 2 Family Dwelling-Number of Bedrooms r Subdivision Name <br /> Block# rr✓�7f).71 i7'e. Id •/4 t-2 te, -- <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use r <br /> Town of S pi--)--1,5, A e- 0 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew S stem ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 1;1 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 /> lon-Pressurized In-Ground ❑ Pressurized En-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/Treatm ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 2.Gallons Gallons Units 2 o $at. <br /> New Tanks Existing Tanks '� ig u w 13 I <br /> a` O r ,n O iZ O 4- <br /> Septic or Holding Tank 1&/_■5-77 / C/ J t ri,(C, /t., <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) Plum gnature _. -.) 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, 53529 <br /> V County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuing :nt Si.nature <br /> $❑ Owner Given Reason for Denial V fill/ ,, ie " , <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x t l inches in size <br /> SBD-6398(R. l l/1 l) <br />