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<br /> "i;•...?-----,-"?.', ,. County
<br /> _• ... . c;N ':Safety and Buildings Division Oct ne ill(
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<br /> 117 .4.:,....,, 1,.,.,. :1 -5 7 201 W Box 7162 Sanitary PermitNumber(to be filled in by C.1.)
<br /> A
<br /> 0.6-'• l'i .-- Madisan,WI 53707-7162
<br /> % '-'.:::-....9 li ,_.------ .
<br /> \\.'4\.._c__'-,. .,....ti,!,,.,V ,pi•Y'
<br /> oyez./a- c-t-ic:-., :3 6
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<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,15.04Xm),Stats.
<br /> I. Application Information-Please Print All Information .-g7 I g (_!:- )1 te.ij f
<br /> Property Owner's Name Parcel 4
<br /> SfQOPY1 OA , 3 v66(5 7 - 0 L/ ( - ci<10 i7 - 0
<br /> Property Owner's Mailing Address
<br /> Property Location
<br /> A I g, 5 $ch tAmon SY- Govt Lot
<br /> City,State Zip Code Phone Number
<br /> 1...,,ca., V., IV 6- th, Section 27f
<br /> %A)e ro:104 CA-ri: 5-3 5-4Z ') N. R (circle one)
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<br /> II.Type of Building(check all that apply) Lot#
<br /> E 1 or 2 Family Dwelling-Number of Bedrooms 3 subdivision Narne
<br /> Block#
<br /> -
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City of
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use
<br /> i-eTowit of goer i;19' ola le
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. 0 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ki.Other Modification to Existing System(explain)
<br /> ke_ 6..v,nee ii---
<br /> B. 0 PermitRenewal 0 Permit Revision 0 List Previous Permit Number and Date Issued 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 /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade Er 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(st) Dispersal Area Proposed(30 System Elevation
<br /> 1.../5-0 7 6 ,........ __
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<br /> VI.Tank Info Capacity in Total #of Manufacturer _ ..
<br /> Gallons Gallons Units I; °
<br /> New Tanks Esistiog Tanks t ° 2 N T g 1
<br /> Septio ur Holding Tank
<br /> /000 /000 / &',:05.tis
<br /> Dosing Chamber
<br /> 60 0 &Co
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
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<br /> Plumber's Name(Print) . Plumbe Signature ,.._ MP/MPRS Number 1
<br /> . STEVEN R. CROSBY
<br /> ( ..,. .. 7-- 227009 608-849-8771
<br /> Plumber's Address(Street,City,State,Zip Code)--- 7' „..,...,----
<br /> 7361 DA.RLIN DRIVE,DANE, WI 53529
<br /> VIII,County/Department Use Only
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<br /> )4 Disapproved
<br /> Permit Fee Date Issued Issuing Agent Signature
<br /> Approved El
<br /> 0 Owner Given Reason for Denial 1 'I 7'It .13//Y if o4 1 fal
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<br /> IX Conditions of Approval/Reasons for Disapproval - .: , . .
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<br /> i 1 ,, :' 1 "■'i:t
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x IlitiChs in size
<br /> SCANNED
<br /> SBD-6398(R. 11/11)
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