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Safety and Buildings Division County Dane <br /> :III iiui ,_'g' 201 W.Washington Ave..P.O.BOX 7162 Sanitary Permit Number Cto be flkd la by CO <br /> "$PS1:i Madison,WI 53747-7162 <br /> a / 3 -261Y-- Jet 4(24' <br /> Sanitary Permit Application State T171 tortiot Number <br /> In accordance with SPS 38321(2).Wis.Mm.Code,submission of this form In the appropriate govenum:mai unit <br /> is moulted prior to obtaining a sanitary prank-Note Application corns for state-owned POWTSere submitted to Project Address Of different than mailing address) <br /> the Department of Safety and Professional Se vhx Personal infonnatmn you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(Ixmk Slats. Uphoff Road <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel,°. <br /> Suzanne&Dylan Anderson 0711-222-8530-0 <br /> Property Owner's Mailing Address Property Location <br /> 416 A W.Clover Lane <br /> Govt.Lot <br /> City,State Tap Code Phone Number NW S5, NW %,section 22 <br /> Cottage Grove,WI 7 (circle one) <br /> „T 7 Ni a 11 EorW <br /> U.Type of Building(check all the . pl Lot 8 <br /> RI Icr2 Family Dwelling-Number of 3 „ 2 Subdivision Name <br /> • block lt:` <br /> ❑Public/Commercial cial-Describe Use F j <br /> :_ J ❑Ciryor • <br /> ❑Stott Owned-1>ercnbe Use - i CSM Number ❑Village of <br /> t3 <br /> 13380 -- ®Tow.or Cottage Grove <br /> Iii.Type of Permit: (Check only one box on Rae A. Complete line B If applicable) <br /> A' C1.New System 0 Replacement-System ❑Treatment/lolclng Tank Replacement Only ❑Other Modification to Existing System(=plain) <br /> - - B. ❑Permit Renewal ❑Permit Revision ❑Change List Previous Perak Number and Duce Issued <br /> aageofPhtmber 0 <br /> Before Expiration Owner <br /> IV.Type of POWTS Systom/Component/Devicer (Check all that apply) <br /> li Non-Premed In-Ground ❑Pressurized is Ground ❑At-Grade 0 Mound?24 is of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Desire(explain) <br /> V.DispersaUTrentment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s() Dispersal Area Proposed(sq System Elevation <br /> 450 0.4 1125 1128 100.7'8t 101.1' <br /> VI.Tank Info Capacity.in Total it of Manufacturer <br /> Gallons Gallons Units E a 1 u <br /> New Tanks Existing Tanks <br /> 1 o 3 i ii— <br /> setmes"i d:asTruk 700/550 1250 1 Crest x <br /> nosing Chamber <br /> VIL Responsibility Statement-I,the undersigned,assume r •- . Malty for Installation of the FOW1TS shown on the attached plans. <br /> Plumber's Nome(Print) Plume's. MP/MPRS Number Business Phoney Number <br /> Po cami. 1 DJ-. —. <br /> Plumber's Address(Street.City.State,Zip Code) <br /> Iyird e / ppp <br /> �� /2C / ii.,_ c-,Z.-_ 5:—gf".e`i <br /> /VU Comity/Department Use O y <br /> KApinovcd ❑Disapproved Permit Fee er Date Issued Issa3 g <br /> ❑Owner Given Reason for Denial S q 0? '^ .S c Aimu_____ <br /> IX Conditions of ApprovaURensons for Disapproval <br /> �I�/-��6 Attach to complete plum far the,.stem and submit to me County only on paper not than 8 to s II ladies hi she <br /> SBD-6398(It.11/11) <br />