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FaTI( <br /> I V} y <br /> r <br /> ?` \ Safety and Buildings Division . CILLrit? ill <br /> (.°i 1 '� 201 W.Washington Ave.,P.O Box 7182 Sanitary <br /> ,..1 L p k t Madison,WI`53707-7162 Permitttumber(to be filled in by Co.) <br /> /3 -2e /7— 49067 <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(t)(m),Stats. <br /> I. Application Information—Please Print All Information f j"fi,e4hr4 Y. /1-& <br /> Property Owner's Name Parcel H <br /> s yrixgctltvfc2 krocip Pmaple lofine Cleobr _ eking —6q.:5 Ylei 6 <br /> Prop} a Owner's Mailing Address ({ Property Location <br /> !W 3132 )\ oeff, ad Govt.Lot <br /> City,State Zip Code Phone Number <br /> /11C y, SW 1/4, Section pt/frietf+mrcG r 535 E <br /> / T S N; R t p E ore) <br /> IL Type of Building(cheek all that apply) Lot# <br /> C I or 2 Family Dwelling—Number of Bedrooms l 1 Subdivision Name <br /> ❑Pubiic/Cornmercial—Describe Use 'c/�i ,4 cv 49 <br /> ❑City of <br /> 0 State Owned—Describe Use CSM Number ❑Village of cr�y <br /> Town of '! Pi n j gjFr/� 1 <br /> III.Type of Permit: (Check only one box on fine A. Complete fine B if applicable) rJ <br /> A' 4 New System ❑ <br /> y Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existin g System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Data Issued <br /> Before Expiration Owner <br /> I.V.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> e -Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>—24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 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(at) System Elevation <br /> Gob t Y /5€ o IS?z. Q4 q - ?.S <br /> VI.Tank Info Capacity in Total it of Manufacturer <br /> Gallons Gallons Units tg U <br /> New Tanks Existing Tanks �i r }�t h <br /> 4 rn ea cn e;v a. <br /> Septic or Holding Tank ,2 8, /i 9<' / /7fewd e X <br /> Dosing Chamber <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 " attire MP/MPRS Number 1 <br /> STEVEN R. CROSBY 227009 608-8 - <br /> Plumber's Address(Street,City,State,Zip Code) -- <br /> 7361 DARLIN DRIVE,DANE, WI 53529 0 b Zp11 <br /> VIII.County/Department Use Only <br /> �� <br /> ❑Approved ❑Disapproved F�� Date Issued issuing Agent Signature volt en 8 N nth <br /> ❑Owner Given Reason for Denial envlrOnm <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete mans for the system sod submit to the County only ea paper not teas than 9 in e It lathes to sloe <br /> SBD-6398(R. 11/11) <br />