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rn-∎;:-. . County <br /> �' Safety and Buildings Division 0a x2 <br /> I d S_ " r 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P.. � j� Madison,WI 53707-7162 <br /> • Sanitary Permit Application State Transaction Number <br /> fn accordance with SPS 38321(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 PO WTS 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 /> L Application Information-Please Print All Information RECEIVED <br /> J <br /> Propert Owner's Name ar el# / <br /> ' �S— <br /> z <br /> ;, Or, <br /> try ire elk (,Z 3 JUL 2 5 1016 6 L-07- ,z 3 Ll - q-)641----0.. <br /> Property Owner's Mailing Address Property Location <br /> 9-8'C ,.1/ Lo t n,Fe r hQ 2d.'( tt..0 He Public Health MDC <br /> ® ity,State k iro�pental H alth /Govt Lot <br /> d ty, Zip Code Yhone Number <br /> St= 'A, 5F 'A, Section V-3 <br /> ® rt 4-c It 19;,c� LtJ. 3 / -.T Ct N. R -� (circle one) <br /> P IL Type of Buildihg(check all that apply Lot# .&77 <br /> ® ' j Subdivision Name <br /> p 1 or 2 Family Dwelling-Number of Bedroo / l <br /> Block# <br /> i ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use lClSJNumber �Vitlage of <br /> `ci ZAp e3 f 114 Town of .5 rr.-= d of 1 e <br /> J <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 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 El 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(g,pd) Design Soil Application Rate(gpdsp Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> CLOG ■ 4 /doU /OCR0I /67, 5 t <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o-a u <br /> New Tanks Existing Tanks " g v 2 u `o H <br /> I!0 in to rn v.O n. <br /> Septic oeplvldfrrg Tank y/ <br /> ea,r <br /> Dosing Chamber J2 G 1 z re- / - i' A'' <br /> C 5v L-S-0 / /71.6',46 € <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 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 /> VIIL County/Department Use Only ,�, <br /> 1&pproved ❑ Disapproved Permit Fee D peed Iss ' A� t Si aturc �`�v{�" " <br /> ❑Owner Given Reason.for Denial $''/6 7 7-20(.( �c <br /> IX.Conditions of Approval/Reasons for <br /> Disapproval <br /> 629-x<-7 - -c fAT , 4b <br /> 1"-^ ,Pt <br /> Forb&N S-O(G co/fry,4&-z-c-0/y role, E ,/ 4\‘' V (jutsiiz_ V;Igc, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ins 11 inches in size <br /> SBD-6398(R 1 I/I I) <br />