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r kb, County <br /> ,,° ,cam ' Industry Services Division DANE Ti <br /> 1>m, ---..„,-',:'-n?-:, `: . 1400 E.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> :�o� '_` LL� Madison,WI 53707-7162 <br /> -' (3-20/5- 000j o <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for stataamedEOWTS are submitted to -73 } <br /> the Department of Safety and Professional Servies. Personal information you provide may l �bsed fo5lsecondary... d PtlOject Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.o4(1Xm),Stars. I -..-- ------_..-.. <br /> I. Application Information-Please Print All Information I _ 1 CTH TT <br /> nn r <br /> Property wner's Name "1 • !. C:i 1 _L;j ; kral# <br /> THOMAS&RENA THOMPSON '0812-042-9030-0 <br /> Property Owner's Mailing Address ,2,77,,, Property Location <br /> 119 VINE ST. SW 'A, NW 'A, Section 4 <br /> City, State, Zip Code Phone Number <br /> SUN PRAIRIE,WI 53590 608 837-3738 T 8 N,R 12 E <br /> II.Type of Building(check all that apply) Lot# 17 1 Subdivision Name <br /> � <br /> 2'1 or 2 Family Dwelling-Number of Bedrooms 4 Block# <br /> ❑Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use 1711.496 ❑Village of <br /> ltv wn of MEDINA <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' l31"<w System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration i New Owner <br /> 'IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> l i" n-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) Pretreatrnent Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Ap cation Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation l� <br /> " 6600 0.4 1500 1500 93.3' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° c• v <br /> New Tanks Existing Tanks u ° V, E 8 , a 2 <br /> 'o <br /> c S) in h ti iz V n. <br /> Septic or Holding Tank 2000 2000 2 DALMARAY X <br /> Dosing Chamber <br /> 1 VII.Responsibility Statement-I,the undersi red,a e responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pl.C.' Si MP/MPRS Number Business Phone Number <br /> I MICHAEL PACHE /F/" 225-065 (608)655-3510 <br /> Plumber's Address(Street,City,State, p Code) <br /> MARSHALL PLUMBING,260 CANAL ROAD, MARSHALL,WI 53559 <br /> VIII.County/Department Use Only <br /> pproved ❑Disapproved Perm ce (7 Date sued Issu -%:7 <br /> ❑Owner Given Reason for Denial S �6 / 77/2// %� C _ 1/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> le(2 q a Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size <br /> SBD 98(R.0313) <br />