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C- xrgvro� County <br /> /� ' Industry Services Division Dane <br /> is r 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> S P.O.Box 7162 <br /> Madison,WI 53707-7162 13-�' r' -��'n C1 SIUNA i J "{ I <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 state-owned POWTS are submitted to - <br /> the Department of Safety and Professional Services. 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. I5.04(1)(m),Stats. Lot 9,Blue Meadow Estates-Albion <br /> I. lication Information—Please Print All Information RECEIVED Panel# <br /> Property Owner's Name <br /> Robert Hostrawser 002/0512-054-5589-0 <br /> JUN 1 5 2015 Pro a rt Y Owner's Mailing Address <br /> Property Location <br /> P.O.Box 787 Public Health MDC <br /> Envi"onmental Hedith Govt.Lot 9 <br /> City,State Z' ode Phone Number SW V.,SE'V.., Section 5 <br /> Stoughton,WI 89 608-213-1807 (circle one) <br /> T 5 N ; R1erW <br /> H.Type of Building(check all that apply) Lot# <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 9 Subdivision Name <br /> Blue Meadow Estates <br /> ❑Public/Commercial-Describe Use Block# <br /> of <br /> ❑State Owned-Describe Use ❑City ge <br /> CSM Number ❑ Villa of <br /> ®Town of Albion <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Number Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground 0 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(sf) System Elevation <br /> 6 0-0 — Ratc(gpdst) o.(f /SO t7 irbet„ e 93. <br /> VI.Tank Info Capacity in <br /> a <br /> Gallons Gallons Units Manufacturer g $ v <br /> New Tanks Existing Tanks S U y 4 g 4:3 iL <br /> Septic or-Heir/ing Tank g f f 1.f.67 — 12Y4 I m e_ad c- _E l- ❑ ❑ ❑ ❑ <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 /> Robert Gingles 901701 608-837-5297 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N8458 County Rd O,Waterloo WI 53594 <br /> VIII.County/Department Use Only <br /> 125-Approved ❑Disapproved Pe Fee Date Issued Issuin ant Si atu <br /> — <br /> ❑Owner Given Reason for Denial $ LH. 6-t 6 2ois <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> -• a ut(C k. y PL4,tf frAneppo c ►n ✓ 6.Z -i A, = (S'° a -.{Q. F>, <br /> -- .SEE ''cP 7 " f(7 eid6w fljow(nro- f2<->°<;4r m iy 7 44" <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches In slat <br /> SBD-6398(R03/14) <br />