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. - <br /> Safety and Buildings Division <br /> '''t ' '7.-i 201 W.Washington Ave„P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> 1 <br /> D )- <br /> Madison,WI 53707-7162 <br /> \III. <br /> p S . <br /> 3.. .:2',-;it.)- OCC-705— <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 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),Stats. <br /> I. Application Information-Please Print All Information Love__ )o Pd' (Pa 55 <br /> Property Owner's Name Parcel# 0'7c.. ; ' i- il (:-,.; <br /> A.5 Owner's 4"111 S ell.) y ) c)/e 1 a.p 44e-,-ct- 4 4C , 0 7 0 1VA-) - 2,Q2-1.2 - 0 <br /> Property ner's Mailing Address Property Location <br /> 75 P 0 i wt., le-4 0 w,v, 7r- Govt.Lot <br /> City,State Zip Code Phone Number 5 V., Ai g 1/4, Section 3A <br /> 1A-r D/1/t.) Cr)-C- 3-3.5- 3 T 7 N; R (circle one) <br /> r E or W <br /> II.Type of Building(check all that apply) Lot I, <br /> RI or 2 Family Dwelling-Number of Bedrooms g ". te, Subdivision Name <br /> Block# Aspon fil,atiows (5.Irifres <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> CSM Number ' 0 Village of <br /> r_l State Owned-Describe Use - - <br /> -' igl Town of "dine hor$1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. l .New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only rif Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> 'Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> lia Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so) Dispersal Area Proposed(sf) System Elevation /6 3,3 <br /> 7 SO / • `.../ . I P 7 r ...- /5' i C) --- zoys,t` J5 /e511,g "9,3 <br /> VI.Tank Info Capacity in Total it of Manufacturer <br /> Gallons Gallons Units <br /> c i rj <br /> New Tanks Existing Tanks t 8 . <br /> iZ c.5 r.. <br /> Septic or Holding Tank /te 1 A eale° IC . <br /> Dosing Chamber i 00 0 .0 lace 1 Meet-e [ <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's Signature-------:- .._/- MP/MPRS Number <br /> STEVEN R. CROSBY 227009 608-849-8771 <br /> / /2-.';' e-( <br /> Plumber's Address(Street,City,State,Zip Co e) .„."/IT <br /> 7361 DARLIN DRIVE, DANE, I 53529 <br /> ( <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing a rd. ignature <br /> Xproved 0 Disapproved <br /> $ L4 .1 -,- <br /> 0 Owner Given Reason for Denial 6 1414iii: •0-44(..- -_ _ _ __ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the CosenAppalaytify II inches in size <br /> SHD-6398(R. I till) <br />