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,f 9,.._A r1(}yr County <br /> �ikfi `-o„,\ ' 3, C1 , Safety and Buildings Division DQ s e �e <br /> ' •0$ ice. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,; P' ~ Madison,WI 53707-7162 <br /> '.F .,.-, / 7)— 0 1 0 1 1 — 0-0 0 / 9 <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 I-0Ue /Os't 1PG- S x <br /> Property Owner's Name Parcel# <br /> Aspert Ceecci i Oe e (cep meni- LI- e ✓ O76� ;3A1 - / oo - or <br /> Property wner's Mailing Addres's' <br /> Property Location <br /> 7 5 'n ra, b le. r0 o LV 41 '7-1.--eye / Govt.Lot <br /> City,State Zip Code Phone Number 3t. '/, N6 in, Section 3 'A , <br /> L)e v n a C ,/I -3 S. q '3 (circle one) <br /> U.Type of Building(check all that apply) Lot# T N; R E or W <br /> al or 2 Family Dwelling—Number of Bedrooms / /U , Subdivision Name <br /> Block# 95pe!'i /2ec c ocv 5 aye-5 <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> 0•Townof ,4'1/'ddle/rh <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ig New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0.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 /> ❑ Non-Pressurized[n-Ground ❑ Pressurized In-Ground ❑ At-Grade c'Mound>24 in.of suitable soLk ❑ 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 Re uired(st) Dispersal Area Proposed(st) System Elevation <br /> Goo ' /, 0/8, <br /> Capa p, 6 6o c) 1boo 60 0//567) /a `1, 3t ' <br /> VI.Tank Info city in Total #of Manufacturer <br /> Gallons Gallons Units .a a o 'g u <br /> New Tanks Existing Tanks u 2 u u is it <br /> a. 0 'vs H rn il.t7 a <br /> Septic or Holding Tank /2-3;4 . P-8-” ' p 2.!rF ('I <br /> Dosing Chamber ?O 0 T v /1'14'20d-el �_ <br /> 00 1 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si re MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE, DANE, W 53529 <br /> V�ounty/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A acute /4.7 <br /> 0-1� °' q7.6./17❑ Owner Given Reason for Denial IX, onditions of ApprovalReasons for Disapproval ti" <br /> ��T�LT NJ©uivD s/T2,4 er .'��� /s Fteer li-►-Nse-0 <br /> flo aru, ire-6-, e-ori-t-rr�r+', EYe-tw4nsrt, a,e t/k//eofe., 7.-eh r,.e /s RP/44W 4,0. <br /> ��pubfc HPalth MDC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 u2Vi�i3f1Yi`ti 1'!fe t Health <br /> h <br /> SBD-6398(R. I lilt) Cll <br />