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SCANNED . <br /> /4.''Ai,4 County /1 <br /> /'f,;,,,.N\ Safety and Buildings Division Dane ca{.°( <br /> 'r U ' v. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) ' <br /> i% ASPS! Madison,WI 53707-716 <br /> ; /5-02,014 —61(-5( ‘-/..S- <br /> - <br /> Sanitary Permit Application Slate 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 pennit.Note Application loom!senate-owned POWTS ore submitted to Project Address(if different than mailing address) <br /> the Deportment of Safety and Professional.Servies. Personal infolomtlon you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.13.041)0T),Slots. Bluff Valley Road <br /> I.Applleadoa lnformadou-Please Print All Information <br /> Property Owners Name Parcel <br /> JustinJozwik,Charlie Allen .'' 0707-284-8041-0 <br /> Property Owner's Mailing Address Property Location <br /> 9337 Windter Frost Place Govt Lot <br /> City,State Zip Code Phone'.Number y,,,-NE ia, SE `d.Section 28 <br /> Madison,WI (cuckone) <br /> II.Type of Building(check all that n ,•) Lot H T 7 N; R 7 E a 1v <br /> ®1 or 2 Family Dwelling-Number of Bed 3 i,--• 1 Subdivision Name <br /> Bieck H <br /> ❑Public/Commercial-Describe Use - ❑City of • <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> X1482 M Town of Cross Plains <br /> M.Type of Permit: (Cheek only one hos on line A.Complete line B If appiicnble) <br /> A. '®New System ❑Replacement System ❑Tream enlliohBng Tank Replacement Only ❑Other IvtodIRcation to Brisling System(=plain) <br /> a•/ <br /> B• ❑.Permit Renewal ❑Permit Revision List Previous Pemtit Number and Date Isssed <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before.Expiration Owner <br /> IV.Type ofPO'hVTS System/Component/Device: (Check all that apply) 1 <br /> ❑Non•I'ressurized In-Ground 0 Pressurized lo-Ground ®At-Gmde ❑Mound Z 24 in.of suitable soil ❑Mound<14 in.of suitable soil <br /> ❑Holding Tardy ❑Other Dispersal Component(espkin) ❑Pretreatment Device(en plain) <br /> V.DlspersalfTreatmeat Area Information: <br /> Design SOW(gpd) Design Soil A-yplication Rale(gpdsl) Dispersal Area Required(s0 Dlsper 1 Area Proposed(sl) System Elevmioa <br /> ' 450 0.6 1-`"750 g----750 92.6' <br /> VI.Tank Info Capacity.in Total H of Manufacturer <br /> Gallons Gallons Units li $ <br /> +� <br /> Nev.Tanks &Ming Tanks ` g °i .ei n <br /> -U m 3 re re.O a. <br /> Septa:ortotdinp Tack 1000/300 1300 1 Dafmaray x <br /> Dosing Chamber 600 600 1 _ Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown an the attached plans. <br /> Plumber's Nome(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> itrno`f\,.� 3' Telle rY'_1,j,QC 2.D-7 5O5 60e-�y:5-7`/>S(� <br /> Plumber's Address(Street,City,Slate,Zip Code) 0 <br /> 1330 Fr:.-1-z Rd. V A..za ■v,M 5359.> <br /> VIII.County/Department Use Only , A <br /> { Approved ❑Disapproved <br /> Permit Pee Date,Issued Issui�%tgant S' • <br /> 5 / / <br /> ❑Owner Given Reason far Denial C /4 j/- 11.' _,j� <br /> - <br /> ConditionsofAgprovnl/Rensonsfor Disapproval �' t <br /> Y <br /> ./ 7 / -( - C y59/AhvE <br /> Attach to complete plass for the erter,and submit to the County only OR paper not teas nun a to s 11 ladles le six <br /> SBD-6398(R.11/1 I) <br />