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r <br /> I `v!�r�!\ County <br /> if F' \;s\ Safety and Buildings Division DA P e ,.J.gtr-- <br /> R S i,' SCAPJNE 201 W.Washingttin Ave.,P.O.Box 7182 sanitary Permit Number(to be filled in by Co.) <br /> Pl. jy1 Madison,WI 53707-7162 <br /> ' 'ice t J -�� / 0o4o <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with SPS 38321(2),Wig.Adm.Code,submission of this form to the appropriate governmental unit <br /> Is required prior to obtaining a sanitary permit (dote:Application forms for state-owned POWTS are submitted to Project dress(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. �� <br /> D. Appli lion Information-Please Print All Information -3 V8 e.4- f' 1.o �) J <br /> P Owner's Name Pal Y / l <br /> r r 3 ' .$a1y D7e)7^ P15. 95a1 — <br /> Property Owner's Malting Wms Property Location <br /> 111 t n . 1f45s I)r- <br /> Govt.Lot <br /> City,State Code Phone Narnber . — ,V4 ,..9../ y* lion a,-- <br /> /'t .l0Q1( 4.14- 7 j �/ T°'_ N; R 1 E or W <br /> IL T e of Building(check all that appl rryy LB:e <br /> 1 or 2 Family Dwelling-Number of Bedrooms c� Subdivision Name <br /> Block i! <br /> ❑Public/Commercial-Describe use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 2owaof Crag” PfA:no <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement eP Only pi Other Modlficatfaa to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plum rmi <br /> ber ❑Pet Transfer to New List Previous Permit Number and Date Issued <br /> Bette Expiration Owner a 16""1 j c/ /4 -Pi- 1i& <br /> IV.Type of POWTS System/Compoaeat/Devies: (Cheek all that apply) rA—,q4)t 714— <br /> ❑Non-Pressurized In-Ground ❑Pressurized[n-Ground 1'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.Dbpersal/Treatment Area In formation: <br /> Design Flow(gpd) Design Soil Application Rala(gptbf) Dispersal Area Required(II) Dispersal Area Proposed(st) System Elevation <br /> VL Tank.Info Capacity in Total - if of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing tab <br /> it <br /> ilHe• wi its.0 G. <br /> Dosing Cheinbec <br /> Teak rba a `4sas1 ( A ) md'ro'y' _ _ <br /> VII,Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Number's Name(Print) MP/MPRS Number <br /> STEVEN R. CROSBY J�hO►,,,. 227009 608-849-$771 <br /> Plumber's Address(Strut,City,State,Zip ) - <br /> 7361 DARL1N DRIVE,D- , 53529 <br /> VIII.County/Department Use Only <br /> wrilm.""Permit Fee Date Issued ,( Aroved ❑Disapproved roved <br /> ❑Ov+nerOivutRemort for Denial a/ ����!' � <br /> IX.Conditions of ApprovallRewns for Dbap oval <br /> •=c.A.7-s<44..-r 1 <br /> elk, r DEC F e Yi;17 <br /> Attack to complete plant rer the system and 3almtt to the County only on paper not less than a to x 11 In Bites!.,, c <br /> [nVil u.ii of_i meal l ktalth <br /> SBD-6398(R. 11/11) <br /> ( <br />