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commerc,.wgOV - µ`7Sa a buildings Division County <br /> ; iA'' 201 W.W n�ton Ave.,P.O.Box 7162 DANE �� <br /> I S C O n o fl J U N - 5 2014 Mat ��,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> It of G arise ', <br /> t I !3 )4 f X/5,3 <br /> State Transaction Number <br /> Sanita Pext; p ' at on ,__. <br /> In accordance with s.Comm.83.21(213V rAdrtt;Code;isllbM5isiotit this fo_ to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(lXm),Stets. JERRY RYAN TRAIL <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel it <br /> DONALD TIERNEY 0911-303-2049-0 <br /> Property Owner's Mailing Address Property Location <br /> 3564 EGRE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW %,SW 'A, Section 11 <br /> DEFOREST 53532 (Cheek One) <br /> II.Type of Building(check all that apply) Lot q <br /> T 09 N; R 11 &I E w <br /> 12 I or 2 Family Dwelling-Number of Bedrooms s 29 Subdivision Name <br /> BRISTOL GARDENS <br /> Block It <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use -CSMNumber ❑Village of <br /> 51 Town of BRISTOL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 51 New System ❑Replacement El Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> System <br /> B. El Permit ❑Permit Revision 111 Change of El Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before 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 11_1 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/1'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Disper#Area Required(at) Dispersal Area roposed(sE) System Elevation <br /> 750 0.6 75 (1250 BASEL AREA) 7 l ?- 'It' 100.5-101.1 <br /> VI.Tank Info Capacity in Total H of Manufacturer( E <br /> Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 1650 1650 1 MEADE Prefab Concrete <br /> Dosing chamber 1000 1000 1 MEADE Prefab Concrete <br /> VII.Responsibility Statement- 1,the undersigned,assume res■onalbiil ■ Ins tattoo of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's i s a j• . MP/MPRS Number Business Phone Number <br /> STEVEN R.CROSBY '7 441111P 227009 608.849.8771 <br /> ' Plumber's Address(Street,City,State.Zip Code) ( <br /> 7381 DARLIN DR. DANE WI 53529 <br /> VIII.County/Department Use Only - -" <br /> _ App ved _ Disapproved Permit F Date ssu Emu' .Agept Signahue <br /> _Owner Given Reason for Denial SO J�r - _ <br /> .Conditions of ApprovavReasons for Disapproval �! <br /> ell) rAttack to complete plans for the system and submit to the County oily on paper not less than 5 us a 1I inches In she transfer-gym peg ss- 2.014-041‘0 -7 g .'K , 3 3 <br /> SBD-6398(R.01/07)Valid thru 01/09 E <br />