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RECEIVED <br /> ,� ,,; AUG 2120 r County <br /> ";:,)..1 % Safety and Buildings Division Dane <br /> ,3r 8�'=y ,V Public Meath MDC 201 W.Washington Ave.,P.O.Box 7162 Sand Permit Number(to be filled in Co.) <br /> rs x$";... Sanitary by <br /> �•�i:p: nvi?octal Health Madison,Wi 53707-7162 <br /> ' . (33 2C$ Oo�6S <br /> Sanitary Permit Application State Transaction Number <br /> to accordance with SPS 38331(3};Wis.Ache.Code,submission otthis form to the appropriate governmental unit <br /> is requited prior to obtaining a sanitary permit.Note Application forms for state-owned POW TS are submitted to Project Address indifferent than mailing address) <br /> the Deparuncnt of Safety and Professional Senior. Personal infomwbn you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. <br /> I.Application Information—Pleose Print All Information <br /> Property Owners Name Parcel# <br /> Barbara Grenlie 0706-262-9500-5 <br /> Property Owner's Mailing Address Property Location <br /> 9973 Greenwald Road Govt La <br /> City,State Zip Code Plume Number SE t;, NW Y.,Section 26 <br /> Mt. Horeb,WI 53572 7 6 (eneleone) <br /> 11.Type of Building(check sill that apply) Lot g T N; R E or 1V <br /> ❑I or 2 Family Dwelling—Number of Bedrooms I Subdivision Name <br /> Convenience Bathroom in Bleek# . 40 Acre Parcel <br /> ®Public/Commercial—Dcseribe use Outbuilding For Owners Lse ❑City or <br /> o State Owned—Describe Use CSM Number <br /> 0 Village of <br /> ®Town of Vermont <br /> III.Type of Permit: (Check only one box online A. Complete line B If applicable) <br /> A" ❑New System <br /> Repiacernatl System ❑Trrmmxmt/lioldiog Tank Replacement Only ❑Other hlodi['tcation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change o(P)umber ❑Permit Transfix to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWrS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground Ea At-Grade 0 Monad>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil cation Ratc(gpdsl) Dispersal Area Required(at) Dispersal Area Proposed(sr) System Elevation <br /> 150 ✓0.6 "250 250 87.3' <br /> VI.Tank Info Capacity In Total #of Manufacturer <br /> Gallons Gallons Units c <br /> New Tanks Existing Tanks y c :'si l $ g <br /> a`u to ,,, 05 'O E. <br /> Septic or Holding Tank 700 700 1 Crest x . <br /> Dosing Chamber 550 _ 550 1 Crrest _ x <br /> ViI.Responsibility Statement 1,the osdersigaed, me responsibility for installation of the POSITS shown an the ailacleed plans. <br /> Plumber's Nome(Print) P Signature MP/MPRS Number Business Phone Number <br /> -Thctui.5 OeSs fcezo$2 tj24{-30/ <br /> Piranha's Address(Street,City,State,Zip Code) <br /> /V7h6? C&a 13e// /( t.' jjv8. <br /> VIII.County/Department Use Only <br /> if-Approved 13 Disapproved Permit F Date Issued Issuing Agent ' are <br /> D Owner Given Reason for Denial S(2(/ 8-261 s <br /> IX.Conditions of Approval/Reasons for Disapproval A <br /> g-26 1 s ,4-5�e... 13 I A.trA. 6,-. ..,....I r 6 t �- / A <br /> wt tl et t.,-e/c>-•- I it-e-7 el f='. 5 . <br /> Attack to complete plans for the system neat submit to the County may no paper not has than a to s t t m aties In sin <br /> SBD-6398(R.11/)1) <br />