Laserfiche WebLink
.:' �� County <br /> %r;. �; \ (. Safety and Buildings Division <br /> $p tai) q��� 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> S <., V Madison,WI 53707-7162 <br /> `..„, --- %% i� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(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 /> • <br /> 1. Application Information-Please Print All Information , mitre-'- / If'o t i i X/,Y,q <br /> Property Owner's Name Parcel# <br /> G' i <br /> Ca t�.I °'- e C bb t Sue 5 t,'t e it_y (') 70 .7- .2 --a- I <br /> Property Owner's Mailing Address — � Cj' C <br /> Property Location <br /> 1V '1 S" CCCt hoc< ?+ 1 <br /> c <br /> City,State ?ovt.Lot <br /> Zip Code Phone Number // <br /> ' A IA-, yl, A/a., 'Y., Section -2 5_ <br /> lie:, r Ct 0 0 LIT 5 3.5 ci 3 T N; R (circle one) <br /> II.Type of Building(check all that apply) Lot# E or W <br /> -l or 2 Family Dwelling-Number of Bedrooms tJ t. . Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> X13 [ ®Town of e.-c�., : ('/ai.,s <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ® New System ❑ Replacement System ❑Treatment/Holding 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 /> [V.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized[n-Ground. ❑ Pressurized In-Ground ❑ At-Grade IN 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) Dispe�rs l Area Required(sO) Dispersal ArP.' •,posed(st) System Elevation <br /> ? CSC c , 6 c//So0 0 G, do <br /> VI.Tank Info Capacity in Total #of Manufacturer /� r, .7 <br /> Gallons - _,_ loxs I[ ' c <br /> Ne auks Existing Tanks a g U <br /> 7 - ,fig n , . <br /> .Gt t �� Crt�c-, a U in H n iL CJ a <br /> Septic or Holding Tank t .7o� "� <br /> /t-%' <br /> Dosing Chamber r <br /> I OOC., I QGQ �C �( <br /> VII.Responsibility Statement-rttie undersigned,assume responsibility for installatioti-ofthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' attire MP/MPRS Number <br /> STEVEN R. CROSBY � ' <br /> —_7 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 ______ <br /> 4 l , _ >,, — <br /> VIII.County/Department Use Ord ' .° , <br /> proved ❑Disapproved Permit Fee Date Issued tssuin gen \. <br /> - <br /> ❑Owner Given Reason for Denial $ 11-*0 ' **.. 1 �'�AR 1 5 21017 <br /> �/� .>IX.Conditions of Approval/Reasons for Disapproval <br /> P blic Health Mix Envi W nmental Health <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x t 1 inc <br /> SBD-6398(R. I Ul 1) <br /> I <br />