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x.4 6 ��I I i County <br /> ,4.1 c,.,_` . ,I Safety and BuilC1! vision Dane <br /> ;f , On;,,K 1 - t j %M a l W.¢ter on A+ in.Box 7162 Smiley Permit Number(m be filled hr by Co.) <br /> P. Madison,WI 5 -7162 <br /> :+'I.; Dub;:c+�i h -f-1,; l 3-20(S—Col 7e- <br /> r: *' later Transaction Number <br /> Sanital t Applid�tiE� -- <br /> S <br /> to acoarden®with SPS 383.2l R).Wis,Adm.Code,submission of this form ion the appropriate governmental unit <br /> is required prior to obtaining o sanitary penniL Norm Application forms for date-owned POWfs am submitted to Project Address(if dilfcmm then mailing address) <br /> the Deportment of Safety and Professional Scream. Personal information you provide may be used far secondary <br /> Purposes to accordance with the Prime),Law,a 15.04(1)(m).Stets. 5632 Schumann Road <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Pored 9 <br /> Sharon Bessa 0807-154-8050-0 <br /> Property Owner's Mailing Address Property Location <br /> 6739 Frank Lloyd Wright Avenue Govt.La <br /> City,Slate Zip Code Phone Number NE ts., SE 14,SeVOon 15 <br /> Middleton,WI 53562 772-1160 (circle one) <br /> II.Type of Building(check all that apply) Lot g T 8 N; R 7 E or w <br /> N I or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Nome <br /> Block k <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ❑State Owned-Describe lee fir)Member ❑Village of <br /> 9876 N Town of Berry <br /> I0.Type of Penult: (Cheek only one box on line A.Complete Hue B If applicable) <br /> A. N New System ❑Replacement System ❑TreatmerniHoidng Tank Replocernem Only ❑Other Moefilicatkm to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Charge of Pkaober ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/ComponentiDevicc: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-Grade ❑Mooed>24 is of suitable soil ❑Mound<24 M.of suitable soil <br /> ❑Holding Tad* ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratelgodsi) Dispersal Area Required(sr) Dispersal Area Proposed(s0 System Elevation <br /> 450 0.4 1125 1128 91.0',92.0' <br /> VI.Tank Info Capacity in Total tl of Manufacturer o <br /> Cottons Gallons traits # <br /> New Tats Existing Tucks l i 11 1 B`E a <br /> ec U to e, rn E 5 E <br /> Septic or Holding Task 1000/600 1600 1 Dalmaray x <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility inflation of the POSITS shown on the attached plans. <br /> Plumber's Name(Print) MMMPItS Number Bustnoss Phone Number <br /> • �V. - _ - <br /> .I Z2L$TL c.os- %/(.5-331y <br /> Plumber's Address(Street,City.State.Zip Code) g' <br /> ggi4 M N.Skiif till 5Sb4 <br /> VIII. natty ens Use Only <br /> Approved ❑Disapproved t Foe. Data Issued Issui g/�j`erey{ (�� p� <br /> ❑Owner Given Raison for Denial - 1V 1,T 4-• —is- _Z.-ft— '/ ,,. .)�- <br /> IX.Conditions of ApprovaVRessoos for Disapproval / <br /> Amacb Is enmplete pleas for the erasers and submit tv the County ant•on paper oar less don a to x 11 inches In sine <br /> SBO-6398(R.)l/I)) <br />