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;` ,� County <br /> �•;%f-.. sue\ Safety and Buildings Division Dane iat <br /> :fir.,:�;n;;.., ;Ty. <br /> ,= g ..':, gi 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ir1 : ;PSF ,ii Madison,WI 58707-7162 <br /> Sanitary Permit Application Stale TrarcmetionNumber <br /> In accordance with SPS 38321(2),Wis.Aden Code,submission ofthic foam to the appropriate govermtmtal unit <br /> is required prior to obtaining a sanitary permit.Note Application forms for slate-owned POWTS are abetttted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used rarsecondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. <br /> I.Application Information-Please Print AU Information <br /> Property Owners Name Panel <br /> Joel&Eve Manke 0509-063-2020-9 <br /> Property Owner's Mailing Address Property Location <br /> 6288 Onwentsia Trail <br /> Govt.Lot <br /> City,State Zip Code - Phase Number NW I,5, SW )G,Seetiat 6 <br /> Oregon,WI 53575 291-0410 <br /> (circle one) <br /> II.Type of Building(check nil that a '� T. 5 N; R 9 E or W <br /> yAe E( amt.):.._ Lola~ <br /> Kit or 2 Family Dwelling-Norther of drowns 5 ./' 80 Subdivision Name <br /> Block it . Partridge Hill Addn.to Ravenoaks <br /> ❑Publie/0antnasia)-Describe Use <br /> ❑city or <br /> ❑Slate Owned-Describe Use CStri Number ❑Village of <br /> 01 Town or Oregon <br /> • <br /> III.Type of Permit: (Cheek only one box on line A. Complete rate B flappable) <br /> A. ❑New S y stem ❑Replacement System ❑TreatmeaUyoldfn C Tank Only tier Other Modlication to Existing System(explain) <br /> Add pump chamber&cell for 5 BR Sy#tem <br /> B. ❑Permit Renewal ❑Permit Revision ❑charge ofPbtmber ❑Permit Transfer to New List Previous Permit Number and Date Issued I( <br /> Before Expiration Owner x ra020 V 7 se`Zm s— <br /> IV.Type of POWTS System/Component/Deviec: (Check ali that apply) <br /> 3 Non-Pressurized In-Ground ❑Pressurized la-Ground ❑At-Grade ❑Monad>24 in.of-suitable soil ❑Mound<24(n.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(grid) Design Soil Application Rate(gpdst) Dispersal Ares Required(st) Dispersal Area Proposed(si) System Elevation <br /> 750 0.6 1250 1350 <br /> _ 99.8' <br /> VI.Tnnk Info Capacity in Total Cot Manufacturer <br /> Gallons Gallons (Jolts 'alp o <br /> Nan Tanks Existing Tanks i' cg .`2 1 .a <br /> Septic aoffeldatgTank -■ 1000/650 1650 . 1 Meade x <br /> Dosing Chamber 800 --� _ 800 _ 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POSITS showat on the attached plans. _ <br /> Py cr's Name(Print Sig�aturc iPRS Number Business Phone Number <br /> 1 W(s 7� /`,•Tr-"�'`(J nc I e� �v. :21,/�;,s Z.J,�Z 5eJ ti...-,‘,3.-S'7 r-32.5"‹ <br /> Plumber's Address(Street,City.State,Zip Code) <br /> VIII.County/Department Use Only <br /> pprovcd ❑Disapproved Permit Fee Data Issued Issuirgl <br /> S y3r r Z 27 4tJ' ) <br /> ❑Owner o;ed Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> To MD Tti veo ckGL r r<Xt.r'fM- J ff7.ct, "a A-ccoor4, 0-...Tivo.. <br /> B A669/h TWA/1:4-i Wow.? -r covYf T e rwA - ✓'E" 71,E <br /> �nr� A-opu c�4� GK�s� / I?' iAX <br /> ( ' '' y q 13 C 9(1 'f i �(r A - 1.- -p' �4 Z <br /> Attach is cnmptate plans for the srstern and submit ts Ma Coasty only an paper awl less than Sills I I Indus In slu <br /> SBD-6398(It.11/11) <br />