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+`f ranrvy`i�; County <br /> X, \.,;\ ' Safety and Buildings Division V6/ nit. <br /> (,� <br /> isr �" 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> i.� p /J� , Madison,WI 53707-7162 <br /> \:: f -vlb <br /> ,��; # 1� /3-- c/-7 toy-4S' <br /> hYUN�y- <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 Sat-vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s, I5.04(1)(m),Stats. /t <br /> I, Application Information-Please Print All Information (..-s:-r'i .-, r� --' <br /> Property Owner's Name Parcel# f <br /> t i t Li;' C 1<y le_ 73rarr,m> f 47) )- 11Y - ‘Q '3c - e.. f <br /> Property Owner's Mailing Address Property Location <br /> c7 I a 1/)'V 4 re. 7r Govt.Lot . . - <br /> City',Atate Zip Code Phone Number <br /> 0 4 4C 6 telj 1� I ff c -5-3-5--. 7 (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T N; R 'P EorW <br /> cal-or 2 Family Dwelling-Number of Bedrooms }7 /(> ' Subdivision Name <br /> Block# "Ale/1"7- 4 d-t'41 e pcirit <br /> ❑Public/Conunercial-Describe Use <br /> ❑City of <br /> I <br /> ❑State Owned-Describe Use CSM Number ❑Village of i <br /> POW',cif �e,4/-A 1e &toYe� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 1 1 <br /> A. blew System . ❑ Replacement System ❑Treatrnent/Hot <br /> VV Ys �/ p ys d6tg Tank Replacement Only IX 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 i <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> D Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 4tPound 7 24 in.of suitable soil ❑Mound<24 in.of suitable soil i <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) ' I <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) /Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispers l Area Proposed(st) System Elevation <br /> (-o b 15 , r "6'oo //dal _ COO 15'9 s 1 C;. ,,S-' <br /> VL Tank Info Capacity in / Total #of rtufacturer <br /> Gallons Gallons Units ° B „ i <br /> New Tanks Existing Tanks A <br /> a. t..) , 0 D a. I a. <br /> Septic or Holding Tank l ale,e, e )Dze4 t ,�/n�� - F/ <br /> Dosing Chamber 8[31. f I �'o o f _ f I"(er (Y �-4-t <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'; 4l elute(-- MP/MPRS Number , <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> C i Plumber's Address(Street,City,State,Zip Code) / .7361 DARLIN DRIVE,DANE, WI 53529 <br /> .VI .county/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing i slur, <br /> ❑Owner Given Reason for Denial $ 0 ki( 7/i!3! 17 i�1//‘-- i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ag r +x wN 1trt , 4 ,c - RECEIVED <br /> I ry 1 rs ` e ).,Jttra►✓. w� An rfr-e6 a ,0si /e/tpy E<l...6,4 ez <br /> ✓Fwtcc4 4.4, 1114.(rre r5 4c-tCwe4, JUL 12 #'017 <br /> Attach to complete plans for the system and submit to the County ontS�p al t d ues In sire <br /> V�.aR/�r�g r,� Public Health MOC ■ <br /> Environmental Health <br /> SBD-6398(R. t l/l i) <br />