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I <br /> ,�{lAM7N'r .- , County �``, <br /> A:,,4 \, Safety and Buildings Division °c <br /> U, S V 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,.WI 53707-7182 1 <br /> I�' , I 3 " bvi ©coo <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(21 Wis.Mm.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 Sorties. Personal information you provide may be used for secondary <br /> purposes In accordance with the Privacy Law,s.15.04{0(m).Stilts. <br /> L Application Information—Please Print All Information (.tile ci i iol&. id <br /> Property Owner's Name Parcel# <br /> Fart'.4 '-11 6 h /c'44iI !If 'f ,h5- 07ox —Dff1- 9eve—S , <br /> Property Owner's Mailing Ad i <br /> tlless Property Location <br /> 7,1 5? 4041 5 IV e. A e ti Govt.Lot <br /> City,State Zip Phone Number 5 Li) V, NO '4, Section ft' <br /> 11 d d ie*61 tar ,- ' ,(circie one) <br /> U.Type ofButiding(check all that apply) <br /> Lot# l E or W <br /> Q§1 or 2 Family Dwelling—Number of Bedrooms, Subdivision Name <br /> Block# 440 re- PprnE/ <br /> ❑Public/Commercial—Describe.Use <br /> 0 State Owned ❑Cityof <br /> GSM Number ❑Village of <br /> d—Describe Use , _l/ <br /> IgITownof rfl ar trn <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pi New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only CS Other Modification to Existing System(explain) <br /> M1. - <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I, <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 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.DispersaUTreatmentArea Information:. <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> 0 e t1 t5-072 rt. 'di r 1S/Z /op.s---/0.2..0 - /OI.9- <br /> VT:Tank into Capacity in Total f of Mann$tcturer: <br /> Gallons Gallons Units o ° <br /> NpwTanks Existing Take 11: i ' <br /> tZr'7 6 <br /> Septic rn Holding Teak ix 9'G 4,2-$6 1 i►toie el—t or . <br /> Pos<psCheraber <br /> Responsibility Statement, I,the undersigned,assume responsibility for installation of the POWTS Shown on the attached plans. <br /> Pluaber's Name(Print) • Plumber's Signaturow MP/MPRS Number I <br /> STEVEN R. CROSBY < � � -- 227009 608-849-8771 <br /> Piumber's.Address(Street, State, Code) <br /> tree(,City, �Zip ) <br /> 7361 DARL1N DRIVE,DANE,WI 53529 <br /> VIII. ounty/Departnient Use Only <br /> P.: Approved 0 Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $❑Owner Given Reason for Denial <br /> Lf° ,day(v . � ,4 <br /> IX.Conditions of Approval/Reasons for Disapproval 1-,(F(''', -, .. i v ;s?t <br /> 4 41tI6rii l4 "106.#75 toNtoo• evrs ?b Bet ofitfitemoveto rDt Gra . t X ; ._.:+ <br /> t••4660 d er5l/oPOC AVON* /s •e441 rvd4. JAN 0 3 zip] <br /> Attach to complete plans The the system and!obeli to the Caan IacheC eOTtfl1elrtl 71 I itdci ith <br /> SBD-6398(R. 11/I l) <br />