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MCLCIVtD <br /> AUG242015 <br /> ��'' 4S- Safety and Buildings Division County Ntt r +U , Public Health MDC 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> `�k Sps° a Environmental Health Madison,WI 53707-7162 „�.._,_".-,.-�_ . <br /> • ``�.+�1� Sanitary Perm , <br /> 13 -aals- 00Q6`7 ,► <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental _ ,--- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Project Address(if different tbat>,mailinu aarlrrsal <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information–Please Print All Information <br /> Property Owner's Name <br /> Parcel#Boyd,Jessica 66 G]—2/if Q/Q — 1 Property Owner's Mailing Address <br /> 2395 CTH B Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number , <br /> se /,,se y, Section 21 <br /> Stoughton, WI 358• (circle one) <br /> II.Type of Building(check all that ,i y) Lot# T s N; R 11 E <br /> 1511 or 2 Family Dwelling—Number of>.. ooms 5 Subdivision Name <br /> ElBlock# <br /> Public/Commercial—Describe Use <br /> E]City of <br /> LiState Owned—Describe Use CSM Number n Village of <br /> al Town of Pleasant Springs <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 111 Replacement D Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> System <br /> B. ❑Permit C Permit Revision n Change of ®Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> , Expiration <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 4 Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 4-Other Dispersal Component(explain) Pretreatment Device(explain) <br /> E z— FGofn/ c. *-wj <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 450 0.4 1125 1125 97.7' <br /> VI.Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic orthnding Tank 1330 1330 1 Dalamaray Concrete Products Concrete <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /MPRS Number ' ess Phone Number <br /> Jeffrey T.Levake 1 _ Zp 223 920-98 67 <br /> Plumber's Address(Street,City,State,Zip Code) "��'1�� <br /> P.O. Box 568 Lake Mills,WI 53551 <br /> VIII.County/Department Use Only <br /> Approved _ Disapproved P ee fj / Si Date I . ed Iss ' Age tore <br /> _Owner Given Reason for Denial $ � k � (y ' r//� � _ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> --)C Z-FGot i cetu e.1 .r 4, = (/2— q, Ff, <br /> e -EcT fit overly iqFo F(7 rl Tf 14'-it. riff cn ryAPC 41'-`e, <br /> -ic. occAkitly� 4'cD j/l�Z Ccf L417.� ,f, C <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R 01/07)Valid thru 01/09 <br />