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V County Safety and Buildings Division Oct rire�j 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> • <br /> Sanitary Permit Application State Transaction Number <br /> rdance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> ired prior to obtaining a sanitary permit Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> partment of Safety and Professional Servies. Personal information you provide may be used for secondary ppes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information (' hi,-j /- <br /> Property Owner's Name Parcel# <br /> W tide d` ill ci are en G le5e. ' 0it07 - 3 `1.3— ?6`i0 a <br /> Property Owner's Mailing Address Property Location &n <br /> G (0 £0_3 1 e tLre 5* G f Govt.Lot <br /> City,State Zip Code Phone Number (,v /, $A) /, Section 3 `/ <br /> PICAIPLe- ©u 56-.G IA JZ 6-.35-7 ? T (circle one) <br /> H.Type of Building(check all that apply) Lot# q N; R 7 E or W <br /> • <br /> gs i or 2 Family Dwelling—Number of Bedrooms , L 3 " Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> wow■• ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> I ie Town of g N K btAesy <br /> J <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t' a New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 'Other Modification to Existing System(explain) <br /> / <br /> B. O.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 /> a 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.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) II/Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation 61/.5-- <br /> (�O0 ' t Li I ( so a / 1 5.--O U FeR•o-S2.P_40.7 - 4/.a <br /> VI.Tank Info Capacity in Total #of Manufacturer ti <br /> Gallons Gallons Units ,o 13 o 'g o <br /> New Tanks Existing Tanks - e w g 13 . _'(. <br /> n O in y rn ii-V G, <br /> Septic or Holding Tank 1 2 YG j 12 a,L ( Q a, Ot! <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa' ro MP/MPRS Number <br /> STEVEN R. CROSBY !j/�� 227009 / 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) =� <br /> 7361 DARLIN DRIVE,DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued Issuing A. azure <br /> ❑Owner Given Reason for Denial 3 z /�si��:..i el. mirxtr. ‘11111111, <br /> IX.Conditions of Approval/Reasons for Disapproval - T ,._ 1• <br /> FEB 282017 <br /> Public Health MDC <br /> p plans system , , �_ a � Irnvirnsize al Health <br /> Attach to complete lane for the s stem an� i V� � not less than 8 to r I l inches in size <br /> I <br /> SBD-6398(R. I I/1 l) <br /> ■ <br />