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• <br /> `i "!_r_1(f∎a, County ,� <br /> Safety and Buildings Division J4-itit J <br /> s/ $ at 11 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '\, `ti P$ �� ? ` Madison,WI 53707-7162 <br /> ,• V <br /> \ twi-y '{.fir 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. 15.04(I)(m),Stats. � / <br /> I. Application Information-Please Print All Information AJ c /-A h' 1/ C- 1- <br /> Proper Owner's Name Parcel# <br /> y --, 4 1 c/z, a/k K 12 7 t%"v c,is ,!, r.5.c., - b).5-5-1 '0 <br /> Propefty Owner's Mailing Address Property Location <br /> 3 (a '7 n rY') 41 Y4 4., 4y Govt. 'ot <br /> City,State Zip Code Phone Number <br /> C----/ii I/y,, JV W y, Section <br /> Vat-a n 40, kf t5 , (circle one) <br /> T 6 N; R R EorW <br /> II.Type of Building(check all that apply) Lot# [=t10fT <br /> �— Subdivision Name <br /> 1 or 2 Family Dwelling-Number of Bedrooms / t,✓4., d- tat))-L.y I-4 s�! <br /> M_ Block# C/ ¢ C-v A , 17'4 3 <br /> II Public/Commercial-Describe Use <br /> ❑City of <br /> CI State Owned-Describe Use CSM Number CI Village of <br /> Town of Ve J-U/\P <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A.New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ril Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal CI Permit Revision CI 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ( 'At-Grade CI Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> CI Holding Tank CI Other Dispersal Component(explain) // Cl Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Des' Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal ea Proposed(sf) System Elevation <br /> Z1. . env O/ , . _ 1--.'"-- JPoP 1-"711/le y,7,U ' i , it,' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 15 o $ _ <br /> New Tanks Existing Tanks . g d 2 g J `A <br /> o b <br /> 0.0 in rn I.t7 0. <br /> i✓S`eptic or Holding Tank L....102 /d S'4 f MC- y <br /> ll Dosing Chamber ���v <br /> id S' <br /> ( /))e-ythi r- <br /> VII.Responsibility Statement- I,the undersigned,-ass 1 e responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb F ature — ___ MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,State, Code) �' ) <br /> ( ty, Zip <br /> 7361 DARLIN DRIVE, DANE, W 29 <br /> VIII.County/Department Use Only 1 <br /> pproved ❑ Disapproved <br /> Permit Fee Date Issued-' Issuing/t nt Signa r%�/ <br /> ❑ Owner Given Reason for Denial (°�0 1,�■/ - I V <br /> IX.Conditions of Approval/Reasons for Disapproval I <br /> S 11 . . ---- __MR ,4-ifi • <br /> Public Health h1DC <br /> \ <br /> Envii•onrnental Health <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l l inches in size <br /> SBD-6398(R. I V I I) <br />