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<br /> ,•,•omuno..;„. county
<br /> i'r.`ri \`^\ Safety and Buildings Division Oh it e .0 fit
<br /> i:ii 9 , ,-,,,.. . 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> Sp 1:1) Madison,WI 53707-7162 -
<br /> ',.',',',- ,: `: , ' ' . 1. ■
<br /> •/4'.< --5',:.F.l 1 3 - ao /(;) - 0 0 3d-a
<br /> ' ',PE
<br /> .....,?10 .-
<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 RECEIVFD Au+,..,,,14; ec,„,f /rer 1'4'
<br /> Property Owner's Name Parcel#
<br /> P- tr. - - i K 111
<br /> c i I C. (" /7/1 l a.Ci 1/'cl th 7- OCT 13 2016 690? - 31 7,- 4.-/I,7-- e) --
<br /> Property Owner's Mailing Address / J Property Location
<br /> Public Health MDC
<br /> .---
<br /> 0 9 *) r C a tAr le Environmental Health Govt.Lot
<br /> Zip Code
<br /> City,State Phone Number
<br /> ili 1,4-1 1/4, ilif-t,' 1/4, Section 3 !
<br /> r 1 e LA)5 -5 3 5—ei 0
<br /> T N; R V (circle one)
<br /> E or W
<br /> II.Type of Building(check all that apply) / Lot#
<br /> <7, ,:h1 tr) ,
<br /> 0 I or 2 Family Dwelling—Number of Bedrooms 7 Subdivision Name
<br /> Block# A Gt-fci m iv rd,i c0 /
<br /> 0 Public/Commercial—Describe Use
<br /> 0 City of
<br /> 0 CSM Number 0 Village of State Owned—Describe Use
<br /> Town of :>19,-,'vr) 1-r
<br /> 1 e/e d
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. Iii,New System / 0 Replacement System 0 Treatment/Holding Tank Replacement Only U Other Modification to Existing System(explain)
<br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 /> 5;1 Non-Pressurized[n-Ground/ 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil
<br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation
<br /> V , L(I , / 5-0 c? /51 2- ' _ q 2
<br /> VI.Tank Info Capacity in Total #of Manufacturer 4)
<br /> Gallons Gallons Units 0
<br /> New Tanks Existing Tanks fs t; C.) 2
<br /> t e 4) 6' -g 1 i' –2
<br /> n. o in . cn Ll..V CL.,
<br /> Septic or Holding Tank 0,
<br /> LIZT6 i.A .(-,, 1 _Pied
<br /> Dosing Chamber 9'0 0 f Ft,0 I Meode X
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installatiOn of e POWTS shown on the attached plans.
<br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number
<br /> STEVEN R. CROSBY
<br /> ( ) --"---- 77:----'- "— 227009
<br /> 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code) ---
<br /> 7361 DAMAN DRIVE, DANE, WI 53529
<br /> VIII. ounty/Department Use Only
<br /> Permit Fee Date Issued Issuing •1 .,Si:. ature
<br /> Approved 0 Disapproved $
<br /> /
<br /> 0 Owner Given Reason for Denial 161/11 tG ---- - "-
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> •
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 X l 1 inches in size
<br /> SBD-6398(R. I.l/11)
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