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i <br /> 1 , <br /> LI Safety and Buildings Division County • <br /> I=.' % .j 1),.,..7._ SCAN . ton Ave., P.O.Box 7162 Sanitary Sanitary Permit Number(to be filled in by Co.) <br /> tY , 5 f WI 53707-7162 <br /> \,• --ter i 1�� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(21 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 /> .0 .uses in accordance with the Privac Law,s. 15.04 1)m),'Stats. <br /> I. Application Informati n-Please Print All Information /�{� Old p <br /> Property Owner's Name A E t�3-, G'� D Cr 5 5 <br /> "�`� '1'� -�cYS4�'T� R Parcel# <br /> • , - • .z - Z 5-,.2 - •Property Owner's Mailing Address n44V_s DAK 64�L <5( <br /> Property Location <br /> City,Sta ;�� '� J��p Gut Lot <br /> `Ck'#r:]t 1 LO - :Zip Code q Phone Number <br /> f Ail - r� fir ( NLC..1 '/., tVt v /., Section 5- <br /> .�{'i�► - `�, (circle one) <br /> U.Type of Building(check all that a ply) �- Lm y- T—ttO N: R E or W • <br /> ❑I or 2 Family Dwelling Dwelling-Number of Vedrooms I i / 1,1 h I;I. 5) Subdivision Name <br /> 77 ea pc- <br /> Block• The ki G3bGQ9 afi t tl a4z h NI /I C 01odd❑Public/Commercial-Describe Use <br /> ❑City of <br /> • <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> fa Town of ffer-dazdr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B, ❑ Permit Renewal 0 Permit Revision ❑Chart a of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration S 0 Transfer to New <br /> Owner <br /> IV,Type of POWTS System/Cornponent/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Grotmd ❑Pressurized In-Ground ❑At-Grade a 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/TreatmentArea Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdst) l Dispersal Area Required(st) Dispersal Area Proposed d(st) System Elevation <br /> Goo / f c)f(,, I G,91 /,c 3' <br /> G tr 7�I 1"" q6,At <br /> VI.Tank Infoapacity in 'Total •of M faaffu ctorer <br /> Gallons Gallons Units <br /> 8 qC 9 <br /> New Tanks Existing Tanks A U ° = <br /> V`" o s = v .8 g id <br /> .U F) � A wC7 a <br /> Septic ge Fluldiag Tank �---. <br /> f Dosing Chambor / P4., 1P y el <br /> .— <br /> 5)o o raC) . I 3c <br /> VU.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) 1 Pluni6e, ign rer27 <br /> 227009 MPIMPRS Number <br /> STEVEN R. CROSBY <br /> 608-849-8771 <br /> • Plumber's Address(Street,City,State,Zip Code) I <br /> 7361 DARLIN DRIVE,DANE, WI 53529 ( ! ' <br /> • VIII,County/Department Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued [ssuin 1 yrr- +ri! <br /> E tc�-�{lQ —� <br /> ❑Owner Given Reason for Denial a / j r� <br /> IX.Conditions of Approval/Reasons for Disapproval "'r Gr�J.�I,t� �`� � t <br /> up- <br /> ` CazNO1`. rB 3 2017 <br /> b'�lL G' /Cf/Yv �jr p i <br /> ( AY ( "'at(cteit `44- .0 0 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 I I finch es in size ntal Health I <br /> fl <br /> :0-6398(R. 1 111 l) <br /> 3 , <br />