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• <br /> "ads ' <br /> -County <br /> Safety and Buildings Division Dane <br /> , ''' 1 201 W W- • —ton Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> i,�1$1;114:44 <br /> ,tP=3i .1 ,W 7 7— 162 <br /> -==�� ; � I El) t 3- 2D(5 - goo SL( <br /> Sanitary Permit Application SteteTmitsaetionNdmber <br /> to accordance with SPS 383.23(2),Wis.Adm.Cgde,submtssron of this form to the appropriate governmental unit <br /> is required prior.to obleining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than moiling address) <br /> the Department of safety and Professional Sen•res, Personal information you provide may be used for secondary . <br /> purposes in accordance with die Privacy Law,s.ls1)4(1)tml,stats. Kaase Road <br /> L Application Infiirtunfloti-Pletise PrintA1l information <br /> Property Owner's Name Parcel 4 <br /> Aaron Ramberg&Erin Kelly-Ramberg 0511-011-8100-0 <br /> Property Oiyner's Mailing Address Property Location <br /> 999 Ash Lane Govt.tot <br /> CO,State • Zip Code:; Phone Number SE ;, NE Y,Salon. 1. <br /> Stoughton,WI 53589 770-3747 (circle one) <br /> H.Type-of Ruilding(check nil that apply) Lot T. 5 14; R 11 E or 1v <br /> ®i or2 Family Dwelling,Number offledroams 4 1 Subdiuisiori Name <br /> 'monks <br /> 0 Pubtic/Commerc�ial-•Describe Use <br /> 0 Cilyor • <br /> 0 stile Owned=-i)escn"be Use CSM Number ❑Vtlloge of <br /> 13158 ®Town or Dunkirk <br /> • <br /> iHr Type of Permit: (Checlt only one tun On line A. Complete line Rif applicable) <br /> A' ®New System ❑Replacement S y stem ❑Treatmentllfioldtn 11ink R ep taccment Oaly 0 Other l4o4lflcollon.to Existing System(explain) <br /> R. 0 Permit Renewal 0 Petn...Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV,T}ape ofPOW'fS System/Component/Devicc; (Check alt that apply) <br /> 13 Non-Pressurized in-Ground ❑Pressuriied In-Ground CI At-Grade ❑Mound>24 in.or suitable soil 0 Mound<24 in.or suitable soil. <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersaifl'rentntent Area Information; <br /> Design flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> 600 0.4 1500 1500 93.0' <br /> VI.Tank Info Capacity in. Total #of Menu lecturer , <br /> Gallons Gallons Units s; P. ,1 o <br /> New Tanks Existing Tanks a u " I I . <br /> tiU i.6 n L.v w <br /> Septic ilL=Tstok 1250 1250. 1 Crest x <br /> Dosing Chamber 750 750 1 Crest <br /> x <br /> ViI,Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP MPRS Number Business Phone Number <br /> Re. erg k.v i-son be t i ,t, /1174 X6 5)5/5'AZpi <br /> Plumber's Address(Street,City,State;Zip Code) <br /> Sat G%hci n 81 O &f,ii le/1- 5-557 <br /> VIII.County/Department Use only <br /> Approved ❑Disapproved <br /> Permit Pee Date Issued lssui Age re <br /> 0 Owner Given Reason for Denial !- U` , if-di--10/c <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans far the system and submit to the County only an paper not less than A in a II to ECE E D <br /> APR 0 8 2015 <br /> SBD-6398(it.t I/1 I) <br /> . PAIR;INNIN OSIC <br /> EMPAORMalitail Naga <br /> 1Iz <br />