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7-5'/----- \f, 1 County <br /> ' <br /> i 'y Industry Services Division DANE K R <br /> iii <br /> 1400 E.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> "c' i.-- ---"..e.../j Madison,WI 53707-7162 <br /> - (3 -20141 - oo385 <br /> Sanitary Permit Application State Transaction Number <br /> AI 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 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if di ercrtt than mailing address) <br /> purposes in accordance with the Privacy Law,s.I5.04(1Xm),Stats. <br /> I. Application Information-Please Print All Information '- is --z:-. TIPPERARY RD. <br /> 1 ��, :,. .l I\:i ! ;, <br /> Property Owner's Name «, )r '' — I Parcel# <br /> DALE D.SECHER �',; i;i I 0509-162-9620-0 <br /> Property Owner's Mailing Address U t NOV - 5 2014 'f Property Location <br /> 5683 LINCOLN RD. 1 1 Sw '/, Nw ''Y4, Section 16 <br /> City, State, Zip Code Phone tii' tti ;'.,iDC f <br /> OREGON,WI 53575 E` '608 235-16311 1 T 5 N,R 9 E <br /> II..Type of Building(check all that apply) Lot 4 2 Subdivision Name <br /> E11 or 2 Family Dwelling-Number of Bedrooms 3 Block 4 <br /> ❑Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use 13826 ❑Village of <br /> i ®'lownof OREGON <br /> — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) . <br /> A. O of System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑Permit Renewal I❑Permit Revision ❑Change of Plumber ❑Permit Transfer to <br /> Before Expiration I New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 113<n-Pressurized In-Ground ❑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.Dispersal/Treatment Area Information: <br /> Design Flow(pd) Design Soil Application RaIe(gpdsf) 'Dispersal Area Required(sf) i Dispersal Area Proposed(sf) I System Elevation <br /> 450 0.4 1125 1128 1 87.8' <br /> VI.Tank Info Capacity in Total ' 4 of Manufacturer <br /> 1 Gallons Gallons Units L c <br /> o <br /> New Tanks Existing Tanks w u o 0 0 ti <br /> c UI c' ,, - 0 Cl... <br /> Septic arigeitil+ng Tank 1000 1000 1 DALMARAY X <br /> Dosing Chamber I I I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 's Sign I MP/MPRS Number I Business Phone Number <br /> SCOTT LOVELACE r 226-852 1 (608)465-3314 <br /> Plumbers Address(Street,City,State,Zip ode) <br /> LOVELACE PUMP COMPANY, INC., 9914 COUNTY M,ARGYLE,WI 53504 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued 'Issuing ent g ur <br /> 1 ❑Owner Given Reason for Denial 1$ tio 11-10-206, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.0313) <br /> 1 got/176, <br />