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, ' ei 9iP t a..ca - /:15/4 <br /> 191_�arrr <br /> ,vr�* • C <br /> 1 o Industry Services Division County DANE <br /> '.� S ,:• �: 1400 E.Washington Ave ' <br /> ', `P$ ,f4; <br /> P.O.Box 7182 Permit Number(lobe titled in by Co.) <br /> S.; Neilson,WI 83707-71 32 a (s <br /> ' - <br /> State Transaction Number <br /> Sanitary Permit Application . <br /> In accordance with SPS 383.21(2).Wis.Adm.Code,submission of this form to the appropriate governmental unit Project Address(if diti:rent than mailing address) <br /> Is required prior to obtaining a sanitary permit Note:Applicetion loans for slate-owned POWTS are submitted to <br /> the Department ofSatbty and Professional Services. Personal information you provide may be used for secondary . ANDOR IANE <br /> tturposes in accordance with the Privacy Caw,s.15.04(19m).Stets. <br /> —Owner's Mune .. •• <br /> PREMIER BUILDERS,tn ugiAddress ._(e'�1 I( 1�1�_ •,,. 2-0557.0 ' <br /> , iorr <br /> 102 N.HOLIDAY DR 91 1 i;41 14* ,,1 : <br /> City,State Zip Code `L Nand, w,NW K, Section 19 <br /> WAUNAKEE, WI 63597 (I (cheek is w) <br /> II.Type of Building(check all that apply) 1 Lot# PIT irc .! tut;;!t 09 ; R 11 l7 g Ow <br /> o I or 2 Family Dwelling—Number of Bedrooms 4 j !• �.h Name <br /> El Pub Uc ommercial—Describe Use <br /> Bock 8 NORWAY ROAD ESTATES <br /> ❑CitY of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> n Town of BRISTOL <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B If applicable) <br /> A' 0 New System ❑Replacement ❑Ta tment/i a 8 Tank Only 0 <br /> System <br /> Other Modification to Existing System(explain) <br /> B. ❑Permit ❑Permit Revision ❑Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Belie Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ItIE Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) OPret,ealmcnt Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rattl) rill:coal Area Required(af) Dispersal Area Proposed(st) System Elevation <br /> 600 0.6 (1.0) ASEL AREA 1000(600) I BASEL119 ,(,808) 1 101.3,101.8 <br /> VI.Tank Info Capacity in Total it of - Manufrurer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Sepik or Holding Tank 1286 <br /> 1286 1 MEADE Prefab Concrete <br /> Dosing Chamber 860 650 1 MEADE Predb Concrete <br /> VII.Responsibility Statement-I,the nude •:•ed,assn,. • .nsiblil x for i ,Hatton of the POWTS shown on the attacked lane <br /> Plumber's Hattie(Print) 077.� <br /> I MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY / � ! 227009 608-849-8771 if- <br /> Plumber's Address(Street,City,State,Zip Code) ' /" r <br /> 7361 DARUN DR. DANE WI 63629 • <br /> ' VIII.Conn /De rtment Use On! A <br /> Disapproved t Foq <br /> _Owner Given Reason for Dental S 2(I/ o '�` j� ''�. <br /> IX.Conditions of Approval/Reasons for Disapproval '%1 <br /> Attach b mom kte goon ear the system and submit to the County only on papa not loss than$Ur x II Inches In also <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />