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• .. <br /> a�eranr.0-ii; County ^, <br /> ,..4-, f {� title Safety and Buildings Division Y q,n/e.. Q 4- <br /> ' ! O 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ y Madison,WI 53707-7162 <br /> ,,,`u,r w�/ pi V l Jot-7 <br /> VIA Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wit 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),.Stars. <br /> I. Application Information-Please Print All Information 'ro 5 p e e-{"'of' Li' <br /> Property er's Name r S t�t,a.1.e.r Parcel ft <br /> rCM46A, $ 7a'. 1ZA � 4thhy m,') 4,L.1:_) 1,- )aY 37 0-0 <br /> Property Owner's/Mailing Address �j } ( Property Location <br /> X10) f T!$-pl yU e,�f /`j of Govt.Lot <br /> City,State ! Zip Cade Phone Number �,/ se ' ,v4 5 g 'f., Section i *° <br /> a) ¢'V Hi' 5- 5-^? (circle one) <br /> U. <br /> ea)/.. <br /> of Bq1 ding(check all that apply) Lot# T N; R /f E or W <br /> '? / <br /> d�►.Ior2Famity Dwelling-Number ofBedrooms ✓ <br /> ‘''''.-5---6, Sudivi�sionName <br /> 4.41043 <br /> Block It 6) AptlL to i;)r.yer-s. <br /> ❑Public/Commercial-Describe Use ❑City of <br /> CI State Owned-Describe Use <br /> CSM Number ❑Village of <br /> Town of 3 i'it, 1Pr4 if'1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ti3.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/ComponeatIDevice: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade d>24 in,of suitable soil ❑Mound<24 in.of suitable soil • <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) 4•� ❑Pretreatment Device*plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appli tion Rate(gpdsf) Dispersal Are equired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 4/54 4 , 4,► '7 S1,, a�� 5 /die) /00, e <br /> VI.Tank Info Capacity in Total #of M cturer <br /> Gallons Gallons Units $ y o <br /> NasTanks Existing Tanks �; v 11 1 <br /> a.U .n ,n a.r7 8-4 <br /> Septio or Holding Tank / 5 t L 1 &le—ei <br /> Dosing Chamber / 60 &PO <br /> VU.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pl . ' _— MP/MPRS Number , <br /> STEVEN R. CROSBY �,.e fir.. ,� 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,ZIp Code) <br /> 7361 DARLIN DRIVE, DANE, WI 53529 <br /> VIII.County/Department Use Only <br /> !+ Approved ❑ Disapproved Permit Fee r Date ued Issui 1 f gent. is ;�: <br /> ❑.Owner Given Reason for Denial /J /7 _..-- .. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> JUL 12 ?U11 <br /> Attach to complete plans For the system and submit to the County only en p r •tlt+tq,N„t/7„X in size <br /> ■R�■■h7i Public Health MDC <br /> nvironmental Health <br /> SBD-6398(R. 11/11) <br />