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`� =ti County <br /> fir..! Safety and Buildings Division I Dane <br /> 17 O3 i-. 201 W.Washington Ave.,P.O.Box 7162 Saniiory Permit Number(to be filled in by Co.) <br /> i., �:. fij Madison,WI 53707-7162 <br /> \N;, J' ( y— 6 4(iS <br /> ';'ate.>• <br /> Sanitary Permit Application Stale Transaction Number <br /> to accordance with SPS 38U1(2),Wis.Mm.Code,submission or this form to dm appropriate governmental unit Trans. ID 2484025 <br /> is required prior to obtninirg a sanitary permit. Note Application forms for state-owned POWTS arc submitted to Project Address(if different then mailing address) <br /> the Depun:neat of Safety and Professional Scrvics. Persona)Jnfcrptatiog voti provide!pay be Used for secondary <br /> purposes in accordance with the Privacy Law,5.15.04(1)L^:j.-Stair -- '.r 1 1- r COray Lane <br /> I. Application Information—Please Print All Information -. <br /> Property Owner's Name I Panel I <br /> Mike&Joni Oliphant DEC 1 1 2014 i I 0607 190-0 <br /> Property Owner's Mailing Address Properly Locution <br /> 3913 Timber Lane _J Govt.Lot <br /> City,State Zip.Cede PhoneNtimba <br /> Verona, WI . ._ SW NE ■JSection 1 <br /> (circle one) <br /> iI.Type of Building(check all that apply - Lot# T 6 N; It 7 E or W <br /> ®I er 2 Family Dwelling-Number of Bed• .rs 4 2 Subdivision Name <br /> Block 4 <br /> D Public/Commercial-Describe Use <br /> D City of <br /> D State Owned-Describe Use <br /> CSM Numb - <br />. ❑Village of <br /> 13529 13 Town of Springdale <br /> iII.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- 51 New System <br /> } D Replacement System ❑Treatmentr7ioiding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> R. D Permit Renewal ! D Pamir Revision D Change of Plumber D Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> i <br /> Before Expiation j Own - <br /> 1 <br /> IV.Type of P0WTS System/Component/Device: (Check nil that apple) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 2 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank D Other Dispersal Cornpument(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow fgpd) Design Soil Application Rate(gpdsl) Dispersal A.i-ra Required(s() Dispersal Area Proposed(s0 System Elevation <br /> 600 0.6 1000 1000 107.2' <br /> Vt.Tank Info , Capacity in Total #or Manufacturer <br /> Gallons Gallons Units ` -t- D <br /> N:w Tanks Existing Tants c . . n n <br /> Septic er Holding Trani: I 700.550 1 1250 1 Crest x <br /> Dcsfor Chacber <br /> } VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb r' Signature r MPIMPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /U-79 (_( (1i 0 19E(l l z )'-' v. <br /> VI .County/Deportment Use Only <br /> i Permit Fee Data Issuing Age- ',v <br /> 1pprovcif ❑Disapproved S ^1 �_ —/ ` <br /> ❑Owner Gieen Reason R.n.Denial jj /J .,-7/// <br /> IX_Conditions pi-Approval/Reasons for Disnpprovrlt j <br /> // <br /> 1.3876( • <br /> Attach rn mmriete plans for the cistern and submit to the County only on paps not less than A t.'_a 11 inches la size <br /> SBD-5343(it. 1 111 1) <br />