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. /`l -1 -j 1,— -?- <br /> ,eeaar1µyr, t�- County <br /> ''� �," ' 7 L Safety and Buildings Division �r��i ....)/1"1 <br /> ja.'' , p S • �. s�yr 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ;i p5 )^j / i - Madison,WI 53707-7162 <br /> __ ,- /9/e-- 1 3- 01-u1-7 - boo 7J 1 <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. I5.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information tc,a,ic j /1t 71 eel, ) <br /> Property Owner's Name Parcel# <br /> f ee,r U �.t�t5 �- OL v5' vs�- ,25-01 v <br /> Property Owner's Mailing Ad ress Property Location <br /> 36 cl b' cWt(J7Q,-- t'-` - Govt.Lot <br /> City,State U Zip Code Phone Number L.- 1 S y,6 , /1'Lc Vs <br /> ' , Section .S <br /> UP r0 VI Cc LU .r 3 (circle one) <br /> II.Type of Building(check all that apply) S.orb `';\t ,1\� T N; R �l E or W <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name j4 e,,,,,,Qo <br /> Block# / <br /> t_ IJti Lpooc . cs.4 Guc.}cJ;. )l 11 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of Ue/'pit ci <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ms New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Li Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New <br /> 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 W 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(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in otal #of M facturer <br /> Gallons Gallons Units :; o u <br /> New Tanks Existing Tanks u c , y <br /> iU v H i1, U a <br /> t Septic pt Holding Tank o_ a,c /.$6 / In a e7ee' <br /> Dosing Chamber s.VS, t / rl� <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 Sigh a MP/MPRS Number <br /> STEVEN R. CROSBY ����_ /j 227009 608-849-8771 <br /> c- <br /> Plumber's Address(Street,City,State,Zip Code) _ _. __ <br /> 7361 DARLIN DRIVE, DANE, WI 53529 '. �``----..-.. <br /> VIII.County/Department Use Only ,e'''' <br /> 1' Approved ❑ Disapproved <br /> Permit Fee Date lssueti f lssui • Agent Sign. .• �� <br /> ❑ Owner Given Reason for Denial �d`lb ! '� <br /> IX.Conditions oof�Approval/Reasons for Disapproval ��� �� <br /> SCANNED <br /> FEB 2 3 '07------- <br /> y 7 <br /> Public Health MDC <br /> Environmental 1-ItItl-I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R. I1/I1) �u..J - rtkv-ic. p?-10%N ,3-01-)- c ibo1 • <br />