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�?o: �. r County <br /> >;,. Y, Safety and Buildings Division P441-f- e (it <br /> /7 D s •. �. r 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> s S ' , Madison,WI 53707-7162 <br /> ■ <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 v 3 Kl'e__ Dr-. <br /> Property Owner's Name Parcel# <br /> 5 2- En44r-t�rr..S4GI t C,, 4'6'-'8 '-f V3.. 7A3 -- 4 <br /> Property Owner's Mailing Address T Property Location <br /> 8 $7 t0bsit rV ,4-4,7 A <br /> Govt.Lot <br /> City, <br /> ell State .(� Zip Code Phone Number t5 4 1, 'J't 1+ Section P <br /> 6 7 1 (4i "4/5 cir e) <br /> II.Type of Building(check all that apply) Lot# T N; R r W <br /> ❑ l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �� 3 so r'r.*y fr`i 14- t"s""e,P.2 <br /> Block# Cam rfrie -c:s4/ C41'tJl4.s' <br /> is/Commercial-Describe Use a ice, L+c.>,tx r t 4 u t.ri `_` <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> itipTown of at es-lilt 9'f-i/e !d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System 0 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 /> on-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(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o u <br /> New Tanks Existing Tanks C v u y <br /> a U 'vi 6, . is. O a <br /> Septic or I-folding Tank 5-.P t 2 1 ee'& Y I <br /> Dosing Chamber 4 . t PP <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plymbe*;.-Sta .1. - 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 /> ❑ Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial <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 a It inches in size <br /> SBD-6398(R. l l/l 1) <br />