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IA,Etun rir��r, County <br /> '; '-t s<r, GANNE fety and Buildings Division p A /V 13 <br /> s!ii"�p� S p 9 ZQ'IWashington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '�t P "� ^7 Madison,WI 53707-7162 <br /> \' '% 5i' ) ^ 13- do/-1- oo c$J- <br /> Sanitary Permit Application State Transaction Number <br /> En accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information L4 :4_A .../. <br /> Property Owner's Name Parcel b O403 . '?3 9 3 6S D <br /> L° )" / tom( Pl � 456 ��) <. nit 4 i f ' .. - - O <br /> Property Owner's Mailing Address EE Property Location <br /> {p 8 r° A"j/9 n LI J�d_ Govt.Lot <br /> City,State / Zip Code ^� Phone Number .S t.1 1,$Ltd / Section s52 <br /> Df; /V e k4). - =, 3- S d �r T 5 N; R 8(circ E one) <br /> U.Type of Building(check all that apply) Lot k <br /> -`l • 2 Family Dwelling-Number of Bedrooms ) Subdivision Name <br /> Block H <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of {-� <br /> 1 YSYY v <br /> l)Townof 4Ne / <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only fif Other Modification to Existing System(explain) <br /> / <br /> B. r] Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Ty le of POWTS System/Component/Device: (Check all that apply) <br /> ,:i Non-Pressurized In-Ground ❑ Pressurized[n-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ 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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> (9p i D :V /Scup /.- 2dr 9x', 5s,, q4., S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a L o v u <br /> •New Tanks Existing Tanks c v U c a <br /> a v, <br /> v.) ic. Q n. <br /> Septic or Holding Tank /g 4,, I ./846 ) ill 4 et d <br /> Dosing Chamber <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' . re MP/MPRS Number <br /> STEVEN R. CROSBY - - 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> 7361 DARLIN DRIVE, DANE . 529 <br /> V�County/Department Use Only <br /> Permit Fee Date Issued Issuing S. nature <br /> Approved ❑ Disapproved <br /> $ <br /> ❑ Owner Given Reason for Denial 40°‘ Wiz'i/ ,-_ <br /> IX.Conditions of Approval/Reasons for Disapproval g <br /> AU6 2 2 2017 <br /> * F.T. 7 (j)S3, J O I-1 - 77 o(,(1* <br /> P rhlic Health t4DC: <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s I I inches kItsi Fironfnt'_Ilt'al 1.1eal1'AI <br /> 1 SBD-6398(R. 1 1/11) <br />