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RECEIVED <br /> SEP11 15 <br /> /�� '!'�v' Safety and Buildings Division County Dane <br /> t :4:74. ,i Public Health M C 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> s _SP. .i Environmental cairn Madison,WI 53707-7162 <br /> �=°_ 13-2015"06253 <br /> Sanitary Permit Application SieteTrmwetiesNumber <br /> to accordance with SPS 383.21(2).Wis.Aden Coda submission oft bb form to Ike appropriate govemmmanal unit <br /> is required prior to obtaining a sanitary penult Note Application forms for stale-owned POWlS are submitted to Project Address(if different Marl mailing addtcss) <br /> the Department of Safety and Professional Solis. Pematal infommian you provide any be used far secondary <br /> purposes in ace a with the Privacy Law,s 13114(1)(mi.Slats. Old Stage Road <br /> I.Application Information-Please Print All information <br /> Properly Owner's Name Parcel a <br /> Ed&Patricia Bierer 0510-352-9580-0 <br /> Property Owner's Mailing Address Property Locution <br /> 2364 Jackson Street#242 Govt Lot <br /> City.State Zip Cade l Phone Number SE %, NW v.Section 35 <br /> Stoughton,WI 53519 N` I 334-5486 (click one) <br /> T 5 N; R 10 EorW <br /> If.Type of Building(check all that apply/ / Lot a <br /> ®I or 2 Family Dwelling-Number of 4 3 Subdivision Nome <br /> Bloat a <br /> ❑Public/Commercfel-Desvile use ❑city or • — <br /> ❑Stone Owned-Describe Use CSM Number ❑Village of <br /> 13829 ®Town of Rutland <br /> ill.Type of Permit: (Cheek only one box on line A.Complete line B if applicable) <br /> A' ®New Systems ❑Replocement Syslon ❑Treatment/HolringTeak Replacement Only ❑Other Mod(fcat(on to Existing System(=plain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑C6onge of Pkmnher ❑permit Temalee to New List Previous Permit Number add Done lasted <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply.) <br /> ®Non-Pressurized In-Gramrd ❑Pressurized la-Ground ❑AI-Grade ❑Monad>24 to.of suitable soil ❑Mond<24 hr.of sable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dlersol Area Requhrd(st) Disposal Area Proposed Isl) System Elevation <br /> 600 0.4 1500 1512 101.7' <br /> VI.Tank Info Capacity in Total 8 of Manufi ervrer <br /> Galion Gallons Units •g $ <br /> New Tanks Existing Tanks a .s,�3 .11 , - 2 <br /> a.0 vs�. vs s.o o. <br /> Septic m iagTarak 1250 1250 1 Crest x , <br /> bodes chamber 750 750 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned, me respoasibWty for Installation of the POW TS shown on the attacked plans. <br /> Plumber's Name(Print). P s Signature MWMPRS Number Business Phone timber <br /> 1-ircv6`(fly\l°(\1'n�,,t -Code) �-"'�/a970.37 ii i'-�/1 <br /> Plumber's <br /> '4 atyQ1 T V gd devr/(P (i✓-. � .3 U <br /> VIII.County apartment Use Only <br /> '7n nppenvaa ❑Disapproved Perish Fee Lased haul <br /> ,� II ❑°ernes Given Reason for Denial /3! 1-(6 !s P(it ( / <br /> IX Conditions of ApprovaVReasons for Disapproval <br /> Atnch la complete plans for the system pad admit is the Calmly oak nn papa not len elan a m s 1 l lashes Is aloe <br /> 580-6395(R.I l/11) <br />