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,,-,: ..ma-2---,e4,,,.igy County <br /> A C 1 y Safety and Buildings Division Oci m e $M <br /> iy(. 9 A.,— 201 W.Washington Ave.,P.O.Box 7162 Sankaty Permit Number(to be fikd in by Co.) <br /> t ' !à:; 7'5-4 4 Madison,WI 53707-7162 <br /> Sanitary Permit Application SudoTterwdtoa Number <br /> In accordance with SPS 3832I(2),Wis.Adm.Code,submission of this tom to the apptaprie goremmmW unit <br /> Is required prior to obWab%a sanitaiy penult.Note Application forum for state-owned POW/3 on submitted to Project Adda ms(rdtftrent thin mailing address) <br /> the Deportment of Satiety and PsoBaioual Semites. Pasonai tdetmadoa you provide may be used tot secondary <br /> pespose,in aeoorde eewith the Messy Law,s.15.04(1xm),Mato <br /> I. Application Information-Please Print All Information <br /> Ptaperty Owner's Name Parcel if <br /> LuilSOn 4 etae srt t.aag h o''L' 30Y° "o <br /> Property Owner's Mailing Address Property <br /> P.o. ee tc coo 3 Govt.tot <br /> City,State Zip Cede Phone Maher y, y,. V.,g <br /> mQdr Se» (44' 33705 f T (aide one) <br /> Ii.Type of Building(cheek off that apply) R�_t=ter W <br /> ®tor2 Family Dwelling-Number ofBedrooms 3 1 Subdivision Mime <br /> Block I <br /> 0 neblUaCammcdd-Donau Use 0 aty of <br /> 0 Sao Owned-Describe Use CSM Number Q village of <br /> '�G 7 �Town of Kos- 'y <br /> • <br /> III.Type of Permit (Check only are box on One A.Complete Ike B if applicable) kr J <br /> • <br /> `t' a New System 0 Repacemai System ❑Trrat/Holdi erg Too Replacement Only ps other ModiSgdon to Existing System(explain) • <br /> 1. 0 Permit Remind 0 Permit Raviaioa 0 Cfsmga of Pauber 0 Permit Transfer to New List Ptevim permit Number and Deer 6sed <br /> Beltae Expiration - owns <br /> IV.Type of POWTS Sys*emlCenpgnemt/Devtce: (Check all that apply) <br /> 0 No,i-P as rhsed In-Oteoad 0 Pre.,aln d let-Ground 0 At.Orada EMfaand>_24 is amiable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Psaiinent Device(enpiaa) <br /> V.DisperaailTreatacot Area Information: <br /> Design Plow(gpd) Ddgs 900 MA:Won Rate( ) - Dispersal Area Required(st) Mensal Area Proposed(s) System Eleveion <br /> YSO <6' Q.40 750_ l.ztl_o 4$.3 t <br /> YL Tank Info Capacity is Total I of Ma tu>wer <br /> Galion Gallons Units ca <br /> Nevereen BxbdaaTanks 1I; .e 1 3.S a 1 <br /> .. at on tZ v o. <br /> sapliaerEtold,tataat /05-0 /o$0 I Mead, <br /> ibdasCamber Coe, 6a Ateort K <br /> VII.i espenslbllty Statement-I,the eadersiped,assume raspoodliffty f r imtallatbn or the POWIS shows a the attached pans <br /> Plumber's Nsne(Print) MlMPRS Number t <br /> __ <br /> STEVEN R CROSBY 0/l 608-849-8771 <br /> Plumber's Address(Skeet,City,Sam,Zip Code) ��' <br /> 7361 DARLIN DRIVE,DANE,WI 535 9 <br /> Viii Coraty/Depat�tmt Use Only <br /> kfii►pproved 0 Disapproved Permit Fee - Date baled Issuing Agent Slgaaoao <br /> 0 Owns Ohm Rados Ox Denial 1P4,- O'b1m1t /f t, :a%=y� <br /> ` T; • <br /> IX.Conditions o[AppnvaUReasoas for DGappco4al er � ..= t , <br /> P.T6cr /y6'a. 6/TE 4.0v 4e4+ it FttT Apwwrss.eod' rw ITS w.Haehe-tool- <br /> . of/1JnW. <br /> Also tet•arynerrerv, P/afrte4 at a reArserase, of ee/JVCara.t c• 77GIF7o+e rte M4i;(7) I'O <br /> Attack to complete plan(vr tee system and sabna Is lbe Comity aaly an qtr®ataa a vt z t1181Biificsiia t, rttut Fi::Atth <br /> SCANNED <br /> SBD-6398(R.1 I/I I) <br />