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1 _ <br /> "`i.arrrt4`rn County <br /> .^'7 Safety `i <br /> f,,,;,. \ � y and Buildings Division <br /> x' Q S fit\ 201 W,Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �t. P '� Madison,WI 53707-7162 <br /> Y. SCANNED <br /> � - ati lj_ dor) oo ? <br /> �SIUNJ�/ r Q l <br /> State Transaction Number <br /> nz az �iizit Application <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(l)(m),Stats. <br /> I. Application Information--PleasePrintAllInformation G, �' )' t2tt <br /> Property Owner's Name Parcel# <br /> 7= h *hi,5//cem e.4 / fl /Juill 076 ' i 3 — 003y- P <br /> Property Owner's Mailing Address Property Location <br /> 76'7/ g ugi ta.► rrVe' Govt.Lot <br /> City,State r2 1 V Zip Code Phone Number y, �4, y, Section 1�f <br /> 56u-"}'h 15e 1 t31,+ ,1 L ild /o 5'(> (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T 7 N; R V' E or W <br /> ll1-1 or 2 Family Dwelling--Number of Bedrooms 6 /L/ Subdivision Name <br /> Block# <br /> P h e a y-cir,J .Pot 37- I <br /> ❑Public/Commercial—Describe Use i <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of ! <br /> &Town of M I'd leacM <br /> m.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' la New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Or 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) i <br /> Iii Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil I I <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) I <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 /> ' o0 _ i Ll ,2.2 5 U P025-0 , 23, ' q3, / , i <br /> VI,Tank Info Capacity in Total #of — Manufacturer <br /> Gallons Gallons Units v v <br /> New Tanks Existing Tanks _ q v ��� A Lt3 5: <br /> Septio osMeltiittg Tank d 0 U .,-,-, oldo 0 1 f110 0 pi, ik- <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. 1 <br /> Plumber's Name(Print) • Plum e, Signaturg•- MP/MPRS Number r <br /> STEVEN R. CROSBY <br /> L 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code)6 <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department.Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issu' A nt gnature <br /> ❑Owner Given Reason for Denial 4 o 7-P f-20/ t � 1 •IX.Conditions of Approval/Reasons for Disapproval - <br /> FEf3 13 2017 <br /> Public Health MDC <br /> • Environmental Health <br /> Attach to complete plans for the system and submit to the County only un paper not less than 8 to x I I Inches in size <br /> SBD-6398(R. t L/I t) t <br /> 3 <br />