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f - \ Safety and Buildings Division M <br /> ;.p ,� 201 W.Washington Ave„ P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> �! S p � t� aL. Madison,WI 53707-7162 <br /> t`'; i <br /> \Ft)I0\. <br /> i 7-dr01)- able <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 /> .0 .oses in accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> I. Application Information-Please Print All Information �'�� ���` 7 <br /> Property Owner's Name Parcel M <br /> Fel .Y' ); btr,v e- t` o (ayb7- dbv- , lSa•- o <br /> Property Owner's Mailing Address // Property Location <br /> .5 V 4 'i:..- (e-re it E`- 4. f1 Govt.Lot <br /> City,State Zip Code Phone Number A/2:- y., /t/.t. I/, Section ,G <br /> Vr 4�t y Jam-3 r� circle one) <br /> Y �' d '?R ! T ,� N; R V E or W <br /> U.Type of Building(check all that apply) Lot II <br /> ("57-2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block II 1 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CS v[N,uambe�JrJ ❑ Village of <br /> 1 Gs !�/ pwn of i-5120 frt._ .4 f, 4 <br /> [II.Type of ermit: (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 /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil Itli 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 Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /c- C5, Sa '''1.('0. /(1. _ 1 4I, l <br /> VI.Tank Info Capacity in Total if of Manufacturer <br /> Gallons Gallons Units V o N t) <br /> New Tanks Existing Tanks ,y g V .. , `‘-1 <br /> C ..) L U <br /> 'S. L) n 5 to iZ(7 0.. <br /> Septic or4Foiding Tank /0 ?e-> '-"-, I 0-- ( /7f/e 4, 'p, <br /> Dosing Chamber 4e-Z"e `-- (,,c I.V. ( <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation oft OWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S': ature / 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, WI 35_9 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issui Aden Sigma re <br /> pproved ❑ Disapproved $ , I <br /> ❑ Owner Given Reason for Denial l a`Cb 6-1-2°(t-� <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Fg.op-k fof C0fk q-cT Sole y....61/44-'0,on- ii, 1 /Y7C1--( • ,FC JUN 0 7 2011 <br /> Attach to complete plans for the system and submit to °l ,n nsr.than 8 in s It inches in size <br /> Public Health MDC <br /> Environmental Health <br /> SBD-6398(R. I I/1 1) <br />