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�/• q County <br /> F �i � s Safety and Buildings Division Dane } <br /> =0 ,,,rl+F� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(ro be SUed in by Co.)" <br /> ' a r,P'''-; Sr Madison,WI 53707-7162 <br /> '`'' 13-2615�Nesi <br /> Sanitary Permit Application Siam TraysaRicaNumber <br /> lo accordance with SPS 38321(2),Wis.Aden.Code,submission of ibis fora ID Ilse epproprinte governmental unit <br /> is required prior to obtaining a sanitary permit.Nolc Application forms for slate•owoed POWfS are submitted to Pmject Address(if different Own mailing address) <br /> the Depunment of Safety and Pmftss(onai Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slots. Flynn Drive <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel 5 <br /> Nate Tengler 0508-072170-0 <br /> Property Owner's Mailing Address Property Locution <br /> 2984 Chapel Valley Road Apt.205 Goof Lot <br /> City,State T„11,Cpde name Number NW ,A, NW%,Section 7 <br /> Fitchburg,WI /" 53711 T 5 N; R 8 (citcc one) <br /> II.Type of Building(check all that apply)// Lot 4 or W <br /> ®I or 2 Family Dwelling-Number of Bedroom' 4 2 Subdivision Name <br /> . Block p <br /> ❑Public/Commercial-Describe use -__/ <br /> ❑city of <br /> ❑Slate Owned-Dcscnbe Use (SM Number 0 Village of <br /> 13453 ®Town of Montrose <br /> Ili.Type of Permit: (Check only one box on UM A. Complete line B If applicable) <br /> A. N New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only <br /> 0 Other Modification to Existing System(explain) <br /> B. ❑Pam(I Renewal ❑Parini Revision ❑Change <br /> of Plumber ❑Permit Transfer to Now <br /> List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POUTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ®At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suiable soil <br /> ❑Holding Tod: ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DLspersal[rreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ita/dgpdsq Dispersal Area Requital(sf) Dispersal Area Proposed(s0 System Elevation <br /> 600 0.6 1000 1000 93.0' <br /> VI.Tank faro Capacity in Total it of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks aiming Tanks E 0 a 3 . a g <br /> aU F, n N f=O a, <br /> Septic or Holding Taub 1250 1250 1 Crest x <br /> Dosing Chamber 750 750 1 Crest <br /> x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the PO11TS shown on the attached plans. <br /> PI •s Nome(Print M P s Signature MMPRS Nmnber Business(None Number oSI t P/ <br /> i�; // Agri hscll j.J, `41cr --- :�Ii 5' ;,(-) .-5---7.5-.3vs'S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ' � , (G/3 A/c rr,, 1,4-/, JT3E1 %� : a4, � , j 57 -////Th <br /> I. <br /> Connty/Dcpartment Use Only <br /> 2CAppro <br /> ved ❑Disapproved Permit Pen <br /> Date Issued Issuing Agc �lutr <br /> t <br /> ❑Otrner Given Raison for Denial Si ! /? 1 z________,i <br /> I.X.Conditions of Approval/Reasons for Disapproval <br /> Attach is tsmmptete Mau fur the system end submit In the Ceanly only no paper ere kas than 8 Ins 11 lode hi the <br /> SBD-5398(R.11/11) <br />