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commerce.wi.gov Safety and Buildings Division County <br /> „ 201 W. Washington Ave.,P.O.Box 7162 DANE <br /> ti <br /> s e o n s I n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (3 - 2-6( (/ /l°4(b <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s Comm.83.21(2),Wis.Adni.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWYS arc <br /> scbr:fired to the Department of Commerce. Personal inhumation you provide may be used for secondary Project Address(if different than mailing address) <br /> :rc:os,s in accordance with the Privacy Law=s, 15.04(I)(n),Slats. <br /> I. Applicalion Information-Please Print All Information <br /> FRANS DRIVE <br /> Po•i:city Owacr',Name <br /> DONALD TIERNEY Parcel# <br /> Property Owner's Mailing Address <br /> Property Location <br /> 2-0 <br /> Property Location <br /> 3564 EGRE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE %,, SW %, Section 30 <br /> DEFOREST, WI ; iH <br /> {.' , I�„ i( l?3�1 � ;C,� (Check One) <br /> I1.Type of Building(check d11)that apply) -• __.. I■f Lot 8 T d9 N; R 11 E W <br /> Ior2 Family Dwelling-NufnberofBedrooi . 4 62 Subdivision Name <br /> BRISTOL GARDENS <br /> NOV 2 5 .�: Block 8 <br /> ❑Public/Commercial-Desehbe Use i 20 L�, , <br /> I <br /> f <br /> L.__ J I I City of <br /> 1>r: c Owned-Describe[Ise U �CSM Number ❑ Village of <br /> .--- ✓ Town of BRISTOL <br /> III,'type of Permit: (Check only one box on line A, Complete line B if applicable) <br /> A' l <br /> ✓I New System I I Replacement I I Trcatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. ❑ Permit ❑ Permit Revision ❑ Change of E Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POW'l'S S stem/Corn)oncnt/Device; Check all that a I <br /> SII Non-Pressurized In-Ground U Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil II Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. 1)kpet•stth,' rcafmcnt Area Information: <br /> ::esi n his(gpd) 1- Design Sod Application Rnte(gpdsl) 1 Dispersal Area Required(al) Dispersal Area Proposed(st) System Elevation <br /> 00 0.4 1 1500 1500 92.6-95.0 <br /> i — l <br /> 1'I.Taal(Info Capacity in 'Total it of Manufacturer Material <br /> I Gallons Gallons Units <br /> New rank, Existing Tasks <br /> Septic or444.lJiug Tank <br /> 1286 "' <br /> 1286 1 MEADE Prefab Concrete <br /> Dosing Chamber 800 800 1 <br /> MEADE <br /> VII. Responsibility Statement- I,the undersigned,assume s onsibllity for Installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plu bet att c MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY .r e.--f 227009 608-849-8771 <br /> Plumber's Address(Street,City,State,Zip Code) '" <br /> 7361 DARLIN DR. DANE WI 53529 <br /> i VI1L Comity/Department Use Only <br /> ,„,/ :∎p ri•v/d r__ Disapproved Permit Fee r,✓ Date Issued Issuing it • nat <br /> 1'' _Owner Given Reason''or Denial $ ,(3( 1 24� y /lie/fir <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i <br /> /i a l O r]t Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s II inches in size <br /> SBD-6398(R.01'/07)Valid thru 01/09 <br />