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rehErpkyp Safety and Buildings Division County <br /> �, Dane <br /> 1 j 201 W.Washington Ave.,P.O. Box 7162 V <br /> x �.,��, !' Madison,WI 53707-7162 Sanitary Permit Number(to be filled In by Co.) <br /> 13`2AI`_b Cam,'t 0 <br /> '/mow. Sanitary Permit Application State Transaction Number <br /> In accordance with s. Comm. 83.21(2),Wis. Adm. Code, submission of this form to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state- Project Address(If different than mailing <br /> owned POWTS are submitted to the Department of Commerce. Personal information you provide may address) <br /> be,Appoloathuadn8brgtplighnsePleaeeftdirtEJkMfonnatiotty Law,s.15.04(1)(m),Stets. <br /> Property Owner's Name Parcel# <br /> 050\0907-183-6121-0 <br /> Jason Kirch <br /> Property Owner's Mailing Address Property Location <br /> 7225 Linsley Lane Govt.Lot <br /> City,State Zip Code Phone Number % y,, Section <br /> Sauk City,WI 53583 (circle one) <br /> II.Type of Building(check all that apply) Lot# T N; R E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms 4 21 Subdivision Name <br /> Block# Blackhawk Fields <br /> Public/Commercial-Describe Use City of <br /> CSM Number Village of <br /> State Owned-Describe Use Town of Roxbury <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. New System Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System <br /> System (explain) <br /> Reconnect <br /> B. Permit Permit Revision Change of 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 At-Grade 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/Treatment Area information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed System Elevation <br /> CO Rate(gpdsf) eeL /Q- —5)(51 17P/1/ <br /> VI.Tank Info Capadty In Total #of Manufacturer m <br /> Gallons Gallon Units E m w ' <br /> New Tanks Existing Tanks S p, ran U ut'i to LL i .t <br /> Septic or Holding Tank <br /> Dosing Chamber <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 /> Brian Elsing t' 1 - 1005477 608-432-4687 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> E10257 Greimel Road, Baraboo,WI 53913 <br /> VIII.County/Department Use Only <br /> XApproved Disapproved $Permit Fee Date Issued Issuing Agent Signature Q <br /> Owner Given Reason for /Gk)\/ 4-29-'5 �(Q� <br /> 40.... a.,e74- oret...c. 0,—,21.1,, ef-2_, ‘d--1/4-- _.e.---is: <br /> Denial c� (7. 4 <br /> .. <br /> ......,40....6.04.fr.e‘i„.. ..... #.4e4.197.7.„72,..ciarf..7 <br /> S D-6 8(R. 10/11) <br />