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`.,09. '"=∎;rte County <br /> /. ;'Yt \:r\ Safety and Buildings Division j�, B/� <br /> �_, ,G S • �, �f ao( 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P �� 7 Madison,WI 53707-7162 <br /> �,c S''k�� �' lo r 3 -J-o/6-- o0 3y-2 <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 )et. t f{ /, rF,. 44J /L <br /> Property Owner's Name g Parcel# <br /> j3%4 c�1 A Awl 1� 5K.,` C ) uA OV 0 e7 y� C - Ups (7/ - 90) 80 y <br /> Property Owner's Mailing Address �U�6 Property Location <br /> h ` 0. 3 i.1 x 4 a D f `jy Govt.Lot <br /> City,State Zip Code Phone Number ,3 Ir y,, N4. y, Section )7 <br /> /7721. da z •tt-0 )",- 5 3 ,5-6-.> 7 (circle one) <br /> Q.Type of Building(check all that apply) Lot# T N; R E or W <br /> ❑ 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> ', Block# <br /> kr Public/Commercial—Describe Use "iR r C-6 9 ie IL <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of )'I <br /> OrCown of 41! 14'! ite-- C1 Ac <br /> IQ.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. r9 <br /> u New System Replacement System ❑ Treatment/Holding Tank Replacement Only 4 r h� <br /> 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 En-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(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> s a o u <br /> New Tanks Existing Tanks w e u u u <br /> 8...- o vi vi v, i.V n. <br /> ep'c or Holding Tank 6 Cf- * rr b ly.t, I C, r, / <br /> Dosing Chamber S 4- ' <br /> ■ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibili y installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) . Plu abe�s Sig lure Z MP/MPRS Number <br /> STEVEN R. CROSBY — _ ,..� 227009 608-849-8771 <br /> _ <br /> Plumber's Address(Street,City,State,Zip Code) ( J <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VII ounty/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing •: .tur fivil <br /> $❑ Owner Given Reason for Denial ��� (I1 i l Ii 6 �� <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 x l I inches in size <br /> SRD-639R(R. 1 1/111 <br />