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Aft;:-::-:`i�xr—;.,� County 41- <br /> \•t\ �. Safety,and Buildings Division .. P4+v•�/ f ~, 201 W:-Washitigton:Ave:, P.0:Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' f r∎ tcskf' . h !'1' r Madison,W(,:53707=7162 <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 POINTS are submitted to Project Address(If different than mailing address) <br /> the Department of Safety and Professional Servies. Personal into oration you provide may be used for secondary <br /> purposes In accordance with the Privacy Law,s.1.5.04(l)(m),Stets. <br /> I. Application Information-Please Print All Information <br /> Property-Owner's Name Parcel# • <br /> �1 i o 4 5- 1 K 6 Sly Z-Oa LA 411,i &11,9 -e 7 02 - t 9' ' 4 <br /> Property Owner's Mailing Address Property Location <br /> ItiV l'� B -' t.`g, /f G/ 73 Govt.Lot <br /> City;State Zip Code Phone Number '/(y 9 <br /> � ' �� ya, Secilon <br /> irate ne) <br /> U.Type ofBuilding(cheek all that apply) .Lot# T '7 N' R W <br /> -r6r 2 Family Dwelling-Number of Bedrooms X • Subdivision Name <br /> _Block# ..—_ _-_-.-- ... 1 <br /> 0 Puhlic/Commeroial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> /9£!9a7 Ti Town of ut.e'►'fit /il- <br /> III.Typ of Permit: (Check only one box on line A.. Complete line B If applicable) <br /> A. few System ❑Replacement System ❑Treatmenh'Holdin Tank Replacement Only M <br /> Ys P Ye g P Y 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 1 <br /> IV.Type of POWTS System/ComponentfDevice: (Check all that apply) • I <br /> i <br /> Mon-pressurized hi-Ground ❑Pressurized in-Ground ❑At•Grade ❑Mound>24 in.of suitable.soil ❑Mound<24 in.ofsuitablesoil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) I <br /> V.Dispersal/Treatment Area Information: 1 <br /> DesignFloty(gpd) . Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation i <br /> 6 0 off i cli P /off R i,..14 i Y,5-,Ir� " <br /> VI.Tank.Info Capacity in Total #of Manufacturer r <br /> Gallons Gallons Units xi S v <br /> New Tanks Existing Tanks w°' c <br /> V �1 ,mot k U in ti w g. c. <br /> Septic ot-�EotdingTenk i!v tfc /2 Pis I m , 4 d[ �Y <br /> Dosing Chamber $'0# --- 151IP 1l r . <br /> VU.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) - Plu.• '' '.. a MF/MPRS Number t <br /> STEVEN R CROSBY .j- - 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7361 DARLIN DRIVE,DANE, " 53529 <br /> VIII.County/Department Use Only <br /> REinproved 0 Disapproved Permit Pee Date issued lssuk Si <br /> ❑Owner Given Reason for Denial $ ( )\ 6-3-2o 7 CXe*„. <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> RECEIVED <br /> � <br /> ',?-, . im r9 Ss..)o r - 054%44 JUL 31 2417 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Uz s It inches Ipatsfic Health mot <br /> SCANNED Environmental Health <br /> SBD-6398(R. L lilt) <br /> �V► <br />