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• <br /> Y' , RECEIVED Cnanty <br /> ii,t,_ tqt) S afety and Buildings Division Dane '{): iltip. , JUL 91015 201 W.Washin Ion Avt7 .P.O.Box 7152 <br /> y ��s 9 a Sm1Unry i'erinG Nuinber(to be'(Media by Co.) <br /> `' - ! i Madison,WI 63707-7102 <br /> ;,F."� Public Health MDC <br /> Fnvironmentat Health • `�-2a�s--co Z t <br /> Trumpet lonNuniber <br /> Sanitary Permit Application Stale Plan Review ID: 13-2015-00200 <br /> In accordance with SPS.383.21(2),Wis.Adm.Code,submission.of this Form to the appruprfale.governMentalonit . .. <br /> - is requitted.prior to obtaining a mnitary);enn1l Note:Apollonian fauns for slate•owned POWTSorc submitted to -Project Address(if different than mailing address) <br /> the Department or Safety aid I'rofcssional Servies, Personal inl'onnationyou provide may be used for secondary <br /> purposl:s in accordance Willi the Privacy.taw,N.IS.0.41)(m);Stals. . ..._ <br /> I. Application lufortiigtlpn._PlensefrintAll:1nformntlon <br /> Propel Owncr's Name Pa rcelti <br /> Eileen Ripp-Ripp's Dairy Valley LLC 0908-361-8003-0 <br /> PropertyOwner'sMillie&Address - - Property Locution <br /> 6626 Ripp Drive Oovt trot <br /> •City;Slate - ' Ziptode PboneNumber NE y, NE ya,Section 36 <br /> Dane,WI 53529 332-9957 (ciicleone) <br /> •H.Typo of Building(chetah-alt that ripply) Loll fi 9 N; R 8 > or 1V <br /> 0 I or 2 Family Dwelling-Number of Dakotans S.obdivlslbn Name <br /> 'bionic 0 . 26.644 Farm Parcel <br /> l Public/Commercial-Describe use Farm Convenience Bathrpom <br /> 0 Cityof. _ . <br /> . <br /> 0 State Owned-Describe Use CSM Nomfiei ❑Village of <br /> ®Town of Dane <br /> • <br /> III.Type of Permit: (Check ably:one hex_on ine A.. Conipletc lineB If applicable) <br /> . A' E]1'4ew System 0 Replacement-System 0 Treatment/Holding Tank Reptacemant Only 0 Other Modification to Existing System(explain) <br /> n• 0 Permit Renewal 0 Permit Revision CI Change of Plumber 0 Permit Transfer to New List Previous Permit Number nail Mute Issued <br /> Before Expiration Owner . <br /> IV.Type ofPOVVTS Systern/Cottiponent/Devieor (Check all that apply) . <br /> 0 Non Pressurized In-Ground 0 Pressurtud In-Ground 0 Al-tirade 0 Mound>24 in.ofsuileblesoll 0 Mound<24 fn,.of suitable soil. <br /> I Holding Tank 0Other-Dispersal-Component.(explain) 0 Prelrculment Device(explain) <br /> V.Dispersal/Treatment Area.lnformlilltin: <br /> Design Flow(gpd) Design Son-Application Rate(gpdsl) Dispersal Area llegolred(at) Dispersal-Area Proposed(st) System Eleva(inn - <br /> 78 _ • <br /> VI.Tank Info Capacity:In Total it or Manufacturer <br /> Gallons Gallons Units <br /> Now Tanks WenngTanks 1 u in 1 T . . <br /> tE0 a <br /> Septic-or Deldlea Teak 2000 2000_ 1 Meade , x <br /> Dostna Chamber <br /> VU.Responsibptty Stntement 1,.t110 undersigned,anumeresponsIbllity for installation of the POWFS shunri en the aliened plans. <br /> Plumber's Name(Print) PI s Signature MMIP/MFRS Number Business Phone Number <br /> SCOT - I 4a - n' '? 03r -7 epq. km-7Lp--au e$ <br /> Plumbers Address(Street,City ode) <br /> • \N155n 1 -e ed l U' ?c(XWI K u4l 5 5154 <br /> wit.County/Department Use Only <br /> Approved ❑Dieopproved Permit F e e onto Issued I , rig _• 1gnatute <br /> 0 Owner Given Reason for Denial S u �. ?/O'�� cue �v <br /> IX.Conditions of Approval/Reasons for Disapproval 1-9 G veV <br /> Minch to complete pleas for the*nom and submit to the Coolly only on paper not less than II la s 11 inches Is size <br /> SBD-6398(R.I l/l I) <br /> I <br /> • <br />