Laserfiche WebLink
---- --RECEIVED <br /> - County <br /> ''. Industry Services Division JUN 29 1015 DANE <br /> 1400 E.Washington Ave.,P.O.Box 7162.ublic Health MD¢Sanitary Permit Number(to be filled in by Co 1 <br /> ,,,` • .. Madison,WI 53707-7162 Environmental H alth <br /> C Permit 13 —Z ol5-- 00lgg <br /> Sanitary r 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 poor to obtaining a sanitary permit.Note-Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servos. Personal information you provide may be used for secondary •Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.13.04(1 km),Stats. <br /> 1. Application Information-Please Print All Information I CTY RD.JJ <br /> Property Owner's Name i Parcel 8 <br /> JAMES ELLESON&KAY BUTCHER )0706-031-9503-0 <br /> 1Property Owners Mailing Address Property Location <br /> 4671 COUNTY HWY 1J SE NE e, Section 3 <br /> City, State. Zip Code <br /> I Phone Number — <br /> BLACK EARTH,WI 53515 608 767-3553 T 7 N,R 6 E <br /> 11.Type of Building(check all that apply) l.ot a Subdivision Name <br /> Ilit or?Family Dwelling--Number of Bedrooms 4 __ Block x <br /> Public/Commercial-Describe Use CSM Number 0 City of <br /> ❑State Owned-Descnbe Use ❑Village of <br /> ar<wn of VERMONT <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. N,•<7.--y System 0 Replacement System ❑Treatment/Holding Tank Replacement Only i 0 Other Modification to Existing System(explain) <br /> B. I❑Permit Renewal ❑Permit Revision ❑Chang List Previous Permit Number and Date Issued <br /> e of Plumber 0 Transfer to <br /> Before Expiration New Owner <br /> I IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> O Non-Pressurized In-Ground CI Pressurized In-Ground 1a3"4t-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 /> i Design Flow(gpd) Design Soil Application Ratetgpdsf) Dispersal Area Required(sf) 1 Dispersal Area Proposed 1st) I System Elevation <br /> 600 0.6 1000 1012 ! 1.00.4' 94.4' <br /> VI.Tank Info Capacity in Total P of Manufacturer i <br /> • Gallons Gallons Units 8 c ' <br /> New Tanks ' Existing Tanks u U - _ _ <br /> ` <br /> o <br /> X E. <br /> ■®,Septic or Holding Tank 1250 1250 , 1 ' DALMARAY i <br /> Dosing Chamber Aso 750 1 I DALMARAY r X <br /> VII.Responsibility Statement-I, the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. _ _ <br /> Plumber's Name(Punt) I Plu�t is Signatur MP/MPRS Number T <br /> Business Phone Number <br /> SCOTT LOVELACE – . 226-852 (608)465-3314 <br /> Plumber's Address(Street.City,State Zip ,odC' e) <br /> —___LOVELACE PUMP COMPANY,INC.9914 COUNTY M ARGYLE,WI 53504 <br /> --- <br /> VIII.CountyiUepartment Use Only <br /> Approved 0 Disapproved Permit Fcc cy; Date Issued ,Issuing Age _ re <br /> . -_- 1 CI Owner Given Reason for Denial $ G-' V7r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to die County only on paper not less than S 12 z I I inches in size <br /> SBD-6398(R.08,14) <br />