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�icauriii� County t, <br /> j� ter' Safety and Buildings Division y^� 7 <br /> Ir;' \' � NEB s 9 /.Num Number x;�S M; 201 W.Washington Ave.,P,O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> >> . . p, 1 ) Madison,WI 53707-7162 <br /> ,�` ` s�`,/ 13- dot-7— 00380k <br /> Any—.-; , <br /> `trrn.n - 1. <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. 2dj E <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> ✓ / <br /> Ref e f AQ'/4 K)cl 5 ? ,5 hf e,114/ rJ 4A s ri N v0,5'Ct q a 797- 94 15--,CS <br /> Prop Owner's Mailing Address Property Location <br /> `?(ifs' 4-i fl r is e. 1I'4 >;-k oc Govt.Lot <br /> City,State / /-2[p Code Phone Number t 't4, NM) y, Section 1 <br /> 0 r-4=q•ry m4 f"-'' • 7 r T 5 Ni R Ctcirc reW <br /> L Type of&Gilding(check all that apply Lot q / <br /> /'LI...." .a' tom'^ <br /> Family s Subdivision Name <br /> /' Block N <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ illage of <br /> tJ`t 3 y -3 t .wn of y'49 41.N <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 121Jew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only tT Other Modification to Existing System(explain) <br /> . <br /> 8. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Betbre Expiration Owner , <br /> IV.Typo of POWTS System/Component/Device: (Check all that apply) ' <br /> iron-Pressurized In-Ground ❑Pressurized In-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: (Alf ta.5,94 t q6.5 <br /> Design/ low(gpd) Design Soil Application Rate(gpdsf) Dispersal/�ea Required(st) Dispersalrea Proposed(st) System Elevation <br /> V 1.5'/7 ,A,1.5— v'/5-4147 v",15-44, 9/ " 9`.50.1 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v <br /> New Tanks Existing Tanks 5 S A A § €i <br /> cC U rn m rn w t7 On <br /> Septic or Holding Tank 4114, r <br /> Dosing Chamber v <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' igna3 MP/MPRS Number <br /> STEVEN R. CROSBY 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 /> Permit Fee Date Issued Issuing Agent Sig a�"$tr--' �,Approved ❑ Disapproved �QQ �j 11 .'t '" :::°""❑Owner Given Reason for Denial $ 11! !f 1� `� "; 1 '.. ¢,.,a�j IX.Conditions of Approval/Reasons for Disapproval ( t �,� 6 <br /> EilVii'iiiii)a�•. . , i <br /> t"'s "z'aith <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 1 L I inches In size <br /> SBD-6398(R. 11/11) <br />