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,ier"arir vr. County <br /> f • \;y. tt(it, 17 Safety and Buildings Division Dame <br /> f I VS �,7 � 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> ' t> , p ` �1,? Madison,WI 53707-7162 <br /> f • . N� Ia..c1 <br /> .'q,� . cot rn <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. <br /> I. Application Information-Please Print All Information SO rt'LA' Of'V e <br /> Property Owner's Name Parcel# <br /> 190,_^1-r't•Cis Rrht_{ I3r00r.51- b G ete 0601 •- 3 C r . -- 4Feo - 6 <br /> Property Owner's Mailing Address ) V Property Location <br /> g g/C1 cir t 4th S treed- Govt.Lot <br /> City,State Zip Code Phone Number ' , , <br /> )1,4 /a, �/,, Section n/�S <br /> w (circle one) <br /> At'dcPle�h tO T N; R EorW <br /> II.Type of Building(check all that apply) / Lot# , <br /> IN I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> re <br /> ❑Public/Commercial-Describe Use <br /> JUN 13 2016 ❑ City of <br /> ❑State Owned-Describe Use CSivI Number ❑ Village of <br /> Public Health MDC C G „„,//f Town of V ee'onei <br /> _Environmental He It�i' � <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ® 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 I Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑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) II Dispersal Area Required(st) Dispersal Area Propose st) System Elevation <br /> VI.Tank Info Capacity in /Total #of Manufacturer <br /> Gallons Gallons Units a 5 8 v <br /> New Tanks Existing Tanks v c u ` Y id <br /> 0 <br /> o.V y v) 4.V i , <br /> Septic or Holding Tank /,�ctn., /R St / Re,./e' ir <br /> Dosing Chamber <br /> ir6 0 lone.) t /,L vee,e-e X <br /> VIII.Responsibility Statement- I,the undersigned,assume • .onsibility for instal r n of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' •'I. re ...11 MP/MPRS Number <br /> STEVEN R. CROSBY A 77.00110"' 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 /> Permit Fee Date Is ue. Iss ' g Agent Si ngtur� / <br /> roved ❑ Disapproved $ <br /> ❑ Owner Given Reason for Denial 1.1;214k° 6 j? j-, -.. <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 1/2 x l l inches in size <br /> SBD-6398(R. 11/1 I) <br />