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{.c.')isdtN <br /> irt C ounty <br /> Safety and Buildings Division 3 -',2,v 1( 9 i31 <br /> ". 0 W.Washington'Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in try Co.) <br /> , ,SPS 1� Mad ison,WI 53707-7162 <br /> "FEfYWN."% <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this RRtrttyC'Itll;..t�fi�`g I unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms s ate w .ii u ed 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 /> JUN 1 7 7Q16 y <br /> I. Application Information—Please Print All Information �4. /7 <br /> Property Owner's Name Parcel# <br /> /� Public Health MDC <br /> OO Na tto <br /> / , . rne,it Environmental Health 6 s'o '-. /1/- TOO— 3 ''' <br /> Property Owner's Mailing Address Property Location <br /> C? t ty s.f- 144.,1 ! 9' Govt.Lot <br /> City,State ii Zip Code Phone Number �fl t/ y,, /1/ %., Section // <br /> W tt LI K Cr u_e e L.f '. 77 (circle one) <br /> R.Type of Building(check all that apply) Lot# T N; R ` E or W <br /> y❑ 1 or 2 Family Dwelling—Number of Bedrooms <br /> /- Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> t Town of .S�t/'tj pgp <br /> r @(G! <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) V J <br /> A. New System/ ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only CI 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 /> 6 Non-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) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation �, <br /> 6O0 1 7 t 5.5-7. /y ' loo q Y. '7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .a o a o <br /> New Tanks Existing Tanks v g u ii 2 A A <br /> a U H o7 iL v a. <br /> Septic or Holding Tank /2 ae‘-- r. /,2 IC. / /'ilP(Qce f oki <br /> Dosing Chamber G 7 6 / 65-0 / A, <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 e •:,.: :, re MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> -, 0Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VI .County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee'i Date Issued Issuing . Signature <br /> 0 Owner Given Reason for Denial � 6/0.41fc ,f, /'y <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 t/2 a 11 inches in size <br /> SBD-6398(R. 11/1 1) <br />