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County <br /> ' ----3\ Safety and Buildings Division <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1, s p - )-I <br /> Madison,WI 53707-7162 <br /> ik,Z s <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(1)(m),Stats. <br /> I. Application Information—Please Print All Information Pt o n e er CJ' <br /> Property Owner's Name Parcel# <br /> Ort'(„trr SfeipAOrtie_ 5-Lvetl,rfei 1070V -,321 - .y'o/ - O <br /> Property Owner's Mailing Address Property Location <br /> //a S <br /> gP cQ 1 r^al I PEI v2 Govt.Lot <br /> City,State Zip Code Phone Number 5 c. 1/4 N E. 1/4, Section 36, <br /> (circle one) <br /> /?'jaCQl SO r? LUr 3 T /0 N. R EorW <br /> U.Type of Building(check all that apply- [�� Lot# <br /> El 1 or 2 Family Dwelling—Number of Bedrooms s -T I I Subdivision Name // <br /> �/ Block# 499..en eaddLta b:sYak? <br /> ❑Public/Commercial—Describe Use � — ''— ❑Ci ty of <br /> CSM Number ❑ Village of // <br /> 0 State Owned—Describe Use ®Town of Mg d `e n <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 U.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 /> ri Non-Pressurized In-Ground ❑ 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(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation /e R, - <br /> 6o) _ t y /5-0C) /6-/.9. /15.7 3. <br /> .-// .?— //R, 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer V e <br /> Gallons Gallons Units <br /> az h.o o = <br /> New Tanks Existing Tanks ai c 8 '� <br /> A cE V in H y u.o a. <br /> Septic or Holding Tank /Z y60 10z e6 / �n/ea(O ra <br /> Dosing Chamber t 8,J t J S'O O I /v/sect ct'P oz- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumieo- �t� (- MP/MPRS Number <br /> 227009 <br /> STEVEN R. CROSBY 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Cod L <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only � ���� <br /> Permit Fee Date Issue Issuing Agent Signature <br /> 0 Approved ❑ Disapproved S r <br /> ❑ Owner Given Reason for Denial _ 5—16-11 "1'44 lii. ci ` E <br /> IX.Conditions of ApprovaVReasons for Disapproval � <br /> PP 1 I 6 2017 <br /> Public Health MDC <br /> Environmental Health <br /> Attach to complete plans for the system and submit to the County only on paper ^r-r ar . f Z.! at <br /> SRD-6398(R. 1 l/ll) <br />