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`,J @AN ,r ��. <br /> j ( r. JI, °'., County and Buildings Division cane J'�`� <br /> { /1-0 S 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> +5 i QS ,:� Madison,WI 53707-7162 <br /> \tt� <br /> „ <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),Stats. <br /> I. Application Information-Please Print All Information Love_ lo 0 ea$S <br /> Property Owner's Name Parcel# C 7cE-f_ 3)--i_ Li f Ca:-- <br /> A s(14-V Ie, )4-y cv le.�44e�- - 44c O7 _ 1 - 4QY�-D <br /> Property ner's Mailing Address Property Location <br /> 75 Pe 7-t.,rh. le-40 of /r Govt.Lot <br /> City,State Zip Code Phone Number 5 to v� , <br /> Ai g /., Section 3 R <br /> zj (circle one) <br /> - <br /> Type of Iding(check all that apply) 3 Lot# T 7 N; R I E or W <br /> ill or 2 Family Dwelling-Number of Bedrooms s '.- /_ Subdivision Name <br /> Block# Co <br /> (}S port /}1Nodows FS1-01E's <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use - <br /> CSM Number ❑ Village of <br /> ®Town of file'd d l€Iprr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I.New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only rj.Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> 'Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> if Non-Pressurized In-Ground ❑Pressurized[n-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation j65,$ <br /> 7 SC) / • y r I re 7 r - /5' I -' la,r-y 16$-.‘1 ass 1.s Mge.I <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o v o_ <br /> New Tanks Existing Tanks - c o = - u g r <br /> a U <n H vi CI.a a <br /> Septic or Holding Tank /65---o -,. /G S d I /h e <br /> ea L�ro <br /> Dosing Chamber j OD o ....• MOO 1 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plt member's Signature - --- < MP/MPRS Number <br /> STEVEN R. CROSBY j 7— - ' 227009 <br /> �,., �, --� 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Co e) <br /> 7361 DARLIN DRIVE, DANE,-- I 53529 <br /> VIII.County/Department Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued Issuing ignature <br /> $ ss�/ <br /> ❑ Owner Given Reason for Denial ��� 61/0 Y/f8 ,�� � <br /> IX.Conditions of Approval/Reasons for Disapproval 7 <br /> Attach to complete plans for the system and submit to the Co nip t s 111 inches in size <br /> ' ' <br /> SBD-6398(R. 1 l/1 l) 1131 � <br />