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,r`iiART\f}_�r,\' , County <br /> !,=;';a \.y,, Safety and Buildings Division Oa,1e. ,�r7t <br /> 5! ? 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) 1 <br /> '.1.4 P S ��i Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit I <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. // -7—;^ I <br /> I. Application Information-Please Print All Information /t k)r lye cti l <br /> Property Owner's Name Parcel# V <br /> /V Ce •f14/x,./ t'e l 1J'ret Zvi J 1./' 0005'-02-6 3- 9!lr0 - U I <br /> Property Owner's Mailing Address Property Location <br /> & 4-b ne P <br /> S 0 r r4 8 {,(,l y Govt.Lot <br /> it <br /> City,State /. ✓. tip Code Phone Number t--r''-- ►. �,ec" y,, rs Lv %, Section :02 G 1 <br /> UPrnna 60 L i..i J'- s'_v (circle one) <br /> 1 . T 4. N; R # E or W <br /> II.Type of Building(check all th apply , Lot# <br /> Subdivision Name <br /> I l or 2 Family Dwelling-Numbe f Bedroo, r t <br /> Block y <br /> ❑PubliclCommercial-Describe se ...- <br /> e R E CE IV�D ❑ City of I <br /> CSM Nu ber ❑ Village of <br /> ❑State Owned-Describe Use I <br /> JAN 0 4 2017 E Town of U e✓U re U <br /> 12-5-ot <br /> III.Type of Permit: (Check only one bopigi,gitill&*thcmplete line B if applicable) <br /> irk� . t-I <br /> A. El New System ❑Replacement gysDte rn olding Tank Replacement Only CI 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 /> t <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade M 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(st)l System Elevation <br /> VI.Tank Info Capacity in oral #of Manufacturer <br /> Gallons Gallons Units a ` a 2 o <br /> New Tanks Existing Tanks c y .12 1 .� 's <br /> o <br /> aV rn iZo C <br /> Septic or Holding Tank t <br /> /6 3-0 /G So / /nece.d, De . <br /> Dosing Chamber <br /> 1000 /000 l /,?q.r4,Gi • De <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum ber' •i MP/MPRS Number <br /> STEVEN R. CROSBY -- 227009 608-849-8771 , <br /> Plumber's Address(Street,City,State,Zip Code) -_ <br /> 7361 DARLIN DRIVE, DANE,WI 53529 -`" <br /> I <br /> yin.County/Department Use Only / <br /> }iiiIX�Approved ❑ Disapproved Permit Fee f Date Issue.I� Issuin _ P?�' <br /> ❑Owner Given Reason for Denial ! <br /> 1 <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 Vex t I Inches In size <br /> SBD-6398(R. 11/11) <br /> i <br /> t <br />