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`4.rxra}`vr. County <br /> ell — t\ A 41 L Safety and Buildings Division D a,i r J m- <br /> I ! (I S A ` 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> I `v p -J Madison,WI 53707-7162 <br /> y! $ i <br /> 'zZPii"- --i.'i" f �O j7 3 OCR <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 333.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application tbrms 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.l5,04(1)(m),Stats. / A� <br /> L Application Information-Please Print All Information �)` 1 !J'L�J, 1P <br /> Property Owe' ame Parce C ( <br /> 4 Ve (in(�_e t,t,e O_.. es 8 , 3?-8 0 o <br /> Proper Owner's Mailing Address (-144.7 J ,�f Property Location <br /> 6).5—y t e`T t s A L✓- ' / CIA ki � ��Goovtt.Lot <br /> City,Site f. ` Zip Code / Phone Number Li'"!.1��_�'A, /tf/fJ_'/, Section 3�J <br /> i%/�-INb/L(t KJ J-- �?.3 5 .'z .,-i-,... c�(circl ne) <br /> �. T N; R d litill <br /> II•Type of Building(check all that app y) Lot# • <br /> ��t or 2 Family Dwelling-Number of Be oms + a Subdivision Name <br /> Block t/ <br /> • <br /> ❑Public/Commercial-Describe Use .--- ❑City of <br /> ❑State Owned-Describe Use CSN[Number ❑Village of <br /> i 7 wn of ,dieb/.17L 4$ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' y'System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) I <br /> { <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> I <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> i <br /> ❑Non-Pressurized In-Ground ❑ Pressurized in-Ground ❑At-Grade trMound>24 In,of suitable soil ❑Mound<24 in.of suitable soil i <br /> i <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Infor ation: <br /> Design 6w(gpd) Design Soil lication Rate(gpdsf) Dispersal Area Re aired(st) Dispers,QI-Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer . <br /> Gallons Gallons Units .n g c�$ y ,� <br /> New Tanks Existing Tanks tt a �i 1 <br /> o @ <br /> aU i'n r, y u:F.5 a <br /> Septio or Holding Tank /0 ff b6"4-- )02()' , ( veieti. , ^�4[ <br /> a <br /> Dosing Chamber � ) b ( ,� ' . <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) unifier's Sig i re _ Number , <br /> STEVEN R. CROSBY i �;, 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) f <br /> 7361 DARLIN DRIVE, DANE, WI 53529 -~----- <br /> VIII.Count /De artment Use Only I J- Milk <br /> Permit Fee Date Issue. Issuing/7, ig . •re-.....7, " <br /> pproved ❑ Disapproved ,' J <br /> $ ,1 <br /> CI Owner Given Reason for Denial r "!6 .. _fir - .. '. <br /> IX.Conditions of Approval/Reasons for Disapproval % �v - t -- .!' <br /> d <br /> 5EB-all <br /> p:,:,w,l!.,.d,-;mix: <br /> Attach to complete plans for the system and submit to the County only an paper not less than a in x II inchel;(ilt i.nemit(tt Ma I t'iut1Ii.i1 <br /> SBD-6398(R. l l/i l) <br />