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RECEIVED <br /> /' JUN Z 9 caaty <br /> i }�( Safety and Buildings Division Dane <br /> 451'; Y pubs.=MNkh mix '201 W Washington Ave..P.O.Box 7162 Sanitary Permit Number(to be Rlkd in by Co.) <br /> i' .;,to3 f Environmental Head) Madison,WI 63707-7162 ` <br /> -.:- A G 2 Z <br /> `��� � 13�-2 r,� o � <br /> Sanitary Permit Application Stem Transaction Number <br /> In accordance with SPS 36321(2),Pits.Adm.code,submission of kb Ram to the appropriate governmental unit <br /> Trans.I D 2555041 <br /> h requited prior lo obtaining s senitery Ienm1.Note Application farms for state-owned POW15 are sohmit ed to Project Address(if different than mailing address) <br /> the Dcpnrsaent of Safety and Prorogued Samba Fanwood infoonam you provide any be used for secondary <br /> Purposes in mordant=with the Privacy t.ew,s.I5.04(I)(m),Slats. Otto Kefi Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Nome Parcel! <br /> Allison Reny&Mike Howell 0807-223-8330-0 <br /> Property Owner's Mailing Addrem Property London <br /> 1812 Westlawn Avenue curt <br /> CRy,Stdb :=?!(r£ed[. `"" Number SE ;t, SW it,Section 22 <br /> Madison,WI _,...--."' T 8 N; R 7 (circle eon) <br /> 11.Type of Building(cheek ' at apply) lot g <br /> El I or 2 Family Dwelling-N of Bedrooms 4 3 Subdivision Name <br /> ■ <br /> 0 PubBe o,umceial-dxnrfoe 0 City or • <br /> 0 Stale owned-Describe Use —1 Number 0 Village of <br /> 11031 ®Town or Berry <br /> III,Type of Permit (Check only one box on fine A.Complete line B If applicable) <br /> A. nu New System 0 Replacement System 0 Treatment/Hokin Took Replacement Only 0 Other Modification to Existing System(explain) <br /> 8. 0 Permit Renewal 0 Permit Revision 0 Cane of Plumber 0 Permit Transfer to New I.Isl Previous Permit Number and Doe Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Systca&Component/Devica (Check aB that apply) <br /> 0 Non•Pressrriad In Omu d 0 Pressurized lo.Groe d I9 At-Grade 0 Mooed>24 hr.of suitable soil 0 Mound<24 ht.of suitable soil <br /> 0 Holding Took 0 Other Dispersal Component(explain) ❑Pretreetment Device(enable) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsp Dltperml Area Required(sr) Dispersal Area Proposed(al) System Elevotio <br /> 600 0.6 1000 1000 101.0' <br /> VI.Tank Info Copachy in Teal N of Manufacturer <br /> Gallen Gallons Units B to . <br /> Nov Talc P ulinr Tadn <br /> 1v A I I-5 a <br /> Sq*leerRaldaaTath 1000/600 1600 1 Dalmaray x <br /> Dakg Chamber <br /> VIL RespousibIlity Statement-1,the a/designed,assume responsibility for butanalloa of the POINTS shown on the attached plans. <br /> .Pr's None(Prim) P a Signet are MI'Ml'RS Number Business Phone Number <br /> 00-Iit-'�-lei ejaCe, . � c ... 22.14 8SZ- -46;-331,' <br /> Pha�ber'r''s Address(Street,City,State.Zip Code` ,`�-,�'+� �y ... <br /> vt/rt'Con(aty srrm4nt Use o�my t I�g �J� <br /> 1l�mwoved 0 Disappeared <br /> Permit Fe+d,.F,- Date Issued Isuiry take t.,/ <br /> _ 0 Owner Given Reason for Denial $ i.j`(•I'✓ ?- s-/J� iJ5 . (,�� <br /> IX.Conditions of Approval/Reasons for Disapproval l �/ <br /> • <br /> Attach le complete ptees far the syvtea ass tsbatt to the Comty sntr m peper oft less thane ra s 11 Iseha M the <br /> SBD-6398(IL 11/I I) <br />