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r <br /> `EpAR(1,,. <br /> �r./-\ � County r <br /> f? 45 N':.,.\ i i Safety and Buildings Division Va rte JL/Y- <br /> / D S :° 201 W.Washington Ave., P.O. Box 7162 <br /> g Sanitary Permit Number(to be filled in by Co.) <br /> P' ��y Madison,WI 53707-7162 <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. IS.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information 5 qm.e <br /> Property Owner's Name �i q Parcel# <br /> C>e atCl �TeamPre (30'305 / OR(l±- zCiY- g000 - 5 <br /> Property Owner's Mailing Address Property Location <br /> 6' ei 11 C'1- 11 Ltr/ /1) / Govt.Lot <br /> City,State Zip Code Phone Number <br /> 5-3 FQt 'y, 5 E 'h, Section AZ 0 <br /> SU i'l Pf�Cil'/'t 2°- �r � 0 T ( N; R //(circle EorW <br /> ) <br /> U.Type of Building(check all that apply) 3 Lot# <br /> 3 Er I or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of . <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of BY-E.g.-6J/ / <br /> [II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System a Replacement System ❑Treatment/Holding Tank Replacement Only g P y 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 /> iR Non-Pressurized In-Grourj ❑ 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> `I5- / , 1 / // 25— / /2on r 96.6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> u e, u <br /> New Tanks Existing Tanks w <br /> aU Cl, ,., . 4., O a <br /> Septic or Holding Tank <br /> Ar <br /> Dosing Chamber (I 5.-U e Le/ Pc ! /J <br /> !'n tGY IJ-C De- <br /> VII.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe' Signature -411111ff MP/MPRS Number <br /> STEVEN R. CROSBY / ,� 227009 <br /> 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) \.. <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> Vounty/Department Use Only y <br /> Approved ❑ Disapproved <br /> Permit Fee Date Issued Issuing ignature <br /> ❑ Owner Given Reason for Denial ��( `//a/1 7 <br /> IX.Conditions of Approval/Reasons for Disapproval �� <br /> z rsrirl - 7-;),,,,,e- is �K' •7pitep SC NNEO <br /> Avg hfc-PeCiV F 4Aft` e fgioe�,,,�_ Y�;a v APR 18 2011 <br /> 1', /�S_ .101)- Public Health MDC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x LFactils'tiniient•aI Health <br /> SBD-6398(R. 1 1/1 I) <br />