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∎•,,%_El.,� County <br /> \` ; ' H Safety and Buildings Division tOci Ara_ J 01 <br /> ')^'I `; 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS , / Madison,WI 53707-7162 <br /> \�`YIUN,,,,Y <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 <br /> Property Owner's Name Parcel# <br /> CA `l /girt 4nca - r~e,iin asbier-fi e r .... OGob- ? a- 9'414,i --.4s <br /> Property Owner'(Mailing Address f / Property Location <br /> /0 Gs 0 7"r / - /7 �f � Govt.Lot Ai 1\j <br /> City,State 1,� Zip Code Phone Number $A1 y/, y., Section d <br /> 712/ ill CS l' I7 a ,33 G'Z T ( N; R (d(circle e) <br /> [I.Type of Building(check all that apply) / Lot# <br /> or 2 Family Dwelling—Number of Bedrooms f V i f Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use J\ y ,- <br /> =a s.r 4.,.. ❑ City of <br /> CSM Number ❑ Village of State Owned—Describe Use Qtr � )� H Town of v)JG. AldVit <br /> g <br /> III.Type of Permit: (Check only one Q fP t,� <br /> olntplete,line B if applicable) <br /> A' ❑ New System , ' lacement System ❑ Treatment/Holding Tank Replacement Only rj.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 Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Pro osed(st) ystem Elevation <br /> l� a or, /bkp -f° rd, 2 '-'-'r 9 ,3 <br /> VI.Tank Info Capacity in Total #of Man acturer f <br /> Gallons Gallons Units 8 <br /> New Tanks Existing Tanks 111 u Iii y <br /> a`0 y . h iZQ a. <br /> Septic or Holding Tank j , r3i- 0,4- �,j�e. ( e- <br /> Dosing Chamber / Y&U. 8 L / ) J <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plgptbe Sig 't.+ <---"`' MP/MPRS Number <br /> STEVEN R. CROSBY i f,< 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, W 53529 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing ent Si <br /> proved ❑ Disapproved $ 1 i ��✓ g �� <br /> ❑ Owner Given Reason for Denial I / �a, / ' ` <br /> IX, nditions oaf A proval/Repsons for Disapproval 6 y, r1a ' '[,i#�� / #►R�- • (�j <br /> ---'tom �7� 72> -ice l►• fir_ ' _ <br /> 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x t l inches in size <br /> SBD-6398(R. 11/t l) <br />