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}. <br /> i <br /> o.� County <br /> r\ �A -Safety and Buildings Division 04 n c 7>11,L. <br /> ;r' f 201 W.Washington Ave P.O. Box 7162 <br /> Madison,WI 53707.-T162 Sanitary Permit Number(to be filled in by Co.) <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) i <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.iS.O4(1)(m),Stats. <br /> I. Application Information-Please Print All Information C4y /IwM <br /> Pro. • Owner's Name ✓ <br /> Parc #' <br /> I Ct/ e 5 04- )< 4 e Lai vie Id 6706, - 361— PO -o p <br /> Property Owner's Mailing Address J <br /> Property Location <br /> of o'Z r lm wood /4 r✓2 t I <br /> City,State Zip Code Phone Number / I <br /> d rX r C��� w %, N(^ '/,; Section <br /> 3 6 7, (circle one) <br /> II.Type of Building(check all that apply) Lot#1 T 7 N; R L E or W <br /> g 1 or 2 Family Dwelling-Number of Bedrooms y Subdivision Name <br /> [lock# <br /> ❑Public/Commercial-Describe Use. <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 4.--7-1: 6 g Town of 1.i 2/•• -e n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> .New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only i <br /> Y 0 Other Modification to Existing System(explain) I 1 1 <br /> B. ❑Permit Renewal ❑Permit Revision ❑Ch <br /> List Previous Permit Number and Date Issued <br /> Betbre Expiration of Plumber 0 Transfer to New <br /> • <br /> Owner • <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground .g At-Grade ❑Mound>24 in,of suitable soil 0 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(sue„ Dispersal Area Proposed(st) System Elevation f�0C r 4 c-- /o V <br /> /eo6, 16. r { <br /> VI.Tank info Capacity In Total #of <br /> Manufacturer <br /> Gallons Gallons Units a i c <br /> New Tanks Existing Tanks } y, p" <br /> u Q . . 1S N as <br /> 4,4 U y V ir.a i1. <br /> Septic or Holding Tank <br /> 142 8'(.• /a?G I inetkd.P ar <br /> Dosing Chamber <br /> it 0U _ re C) / rheaoe r~ <br /> Vfl.Responsibility Statement- I,the undersigned,assum a Ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) • Plumber's 5ign'l MP/MPRS Number <br /> STEVEN R. CROSBY / 227009 <br /> -------_ I 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Cade) - <br /> 7361 DARL1N DRIVE, DANE, WI 5 2" <br /> VII ounty/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued [ssui Si nature <br /> ❑Owner Given Reason for Denial $ 1.4.1/46,,, 110 <br /> 111 1{{ t 66 ./4°�` , <br /> IX,Conditions of Approval/Reasons for Disapproval <br /> RECEIVED I <br /> Attach to complete plans for the system sad submit to the County only�n,oa noes flan a us s II Inches In size ` T <br /> SBD-6398(R. !t/I l) iVr: j�� r :c`a,.- Public Health rrIpC i <br /> .._".,.,. . ,_ Environmental Health <br />