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YAa'fl� <br /> ■ <br /> i .....".•-::,ype $Y��\ County <br /> -1' °r.\ Safety,pnd 13 (dings Division 0411 J <br /> („ S / 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ;,, _ ! 1 Madison,WI 53707-7162 <br /> v, !/ 1. 26 fly} <br /> �YIUNA�� ` <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. , <br /> I. Application Information—Please Print All Information fro n 15 Or I v_. <br /> Property Owner's Name Parcel# <br /> Oat.t'd 44. wend ciy Xctvtn e Oct ii- 303- 05'8-'1 - 0 <br /> Property Owner's Mailing Addro§s Property Location <br /> 303 s' i(Anker Vw <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Sr Yti ,$'w '/,, Section 3b <br /> SG n Pro' <br /> I Pie t u 5 3 S'' O T 4 N; R !! EorW <br /> one) <br /> U.Type of Building(check all that apply) Lot# <br /> ®I or 2 Family Dwelling—Number of Bedrooms i'?! G q Subdivision Name <br /> Block# 6ri'8+d/ Gaa'jPn S <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSiV[Number ❑Village of ■ <br /> ®Town of 6rr5 /-'l <br /> • <br /> ILI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ®New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 ❑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 Sojl-Application Rate(gpdst) Dispersal Area Required(st) ' Dispersal Area Proposed(sf) System Elevation <br /> 6 0 o . '-/ `/ 15-00 A-/r/A <br /> VI.Tank Info Capacity in Total #of Manufacturer 4�0 ��� `��' 45 <br /> G. <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks c <br /> � <br /> U fn �a i vi ii.v 4 <br /> Septic or Holding Tank <br /> /.pt SSG /A8'4 / MOQ GOP <br /> Dosing Chamber 1e0 V PO 0 / mead s a' <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,Sign MP/MPRS Number <br /> STEVEN R. CROSBY --ii. 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 /> /0<kproved ❑ Disapproved Pe it Fee w Date Issued [ssuin/Agent Si:��� <br /> )proved <br /> Given Reason for Denial 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 I/t a l t Inches in size <br /> SBD-6398(R. 11/11) <br />