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Safety and Buildings Division County <br /> WilV 2 01 W.Washington Ave.,P.O.Box 7162 DANE . <br /> sconsIn Madison,WI 53707—7162 Spnitary Permit m Nu er(t be fill d in by Co.) <br /> Department of Commerce (608)266-3151 yC2 g 5o 0623 <br /> Sanitary Permit Application State Plan I.DNum r <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide e .NT J tV <br /> may be used for secondary purposes Privacy Law,s15.t)4(lXm) Project Address(if different than mailing address) <br /> I. <br /> I.'Application Information—Please Print All Information 593 WASHINGTON ROAD <br /> Property Owner's Name Parcel# Lot# Block# <br /> DEE HEITZ 026/0511-244-9500-0 <br /> Property Owner's Mailing Address Property Location <br /> 669 CTH N <br /> SE % SE %, Section 24 <br /> City,State Zip Code Phone Number <br /> STOUGHTON, WI 53589 608-873-9899 5 11(circleone) <br /> II.Type of Building(check all that apply) T N; R ,E,or}az, <br /> 0 I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name ��� l I CSM Number <br /> Public/Commercial--Describe Use <br /> ❑State Owned-Describe Use ['City []Village 17 township of DUNKIRK - <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System S Replacement System} p y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> R. ❑ Permit Renewal ❑Permit Revision ❑ Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil IZI Mound<24 in.of suitable soil ❑At-Grady, ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: _ —' -- <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) ' Dispersal Area Proposed(sf) System Elevation <br /> 300 .6 1357.5 BASAL AREA 1357.5 BASAL AREA 99.5 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 1000 1 CREST, INC. X <br /> Aerobic Treatment Unit <br /> DosingChamber 600 600 1 CREST, INC. X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 2er'u Signal MP/MFRS Number Business Phone Number <br /> JOHN E. RASMUSSEN -K/ f.1 223732 608-635-4305 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> ARLINGTON HARDWARE, IN ., 303 MAIN STREET,ARLINGTON,WI 53911 <br /> kit <br /> VIII.County/Department Use Only _ -.1111 <br /> Approved ❑ Disapproved Sanitary Permit ee(includes Groundwater Date Issued Issu',_,•g f j apt(No Stamps) <br /> Surcharge F t s I) �jG.�,'i e.S. <br /> ❑Owner Given Reason for Denial N ING THIS APPROVAL,DANE CO��i,l� � <br /> IX.Conditions of Approval/Reasons for Disapproval ENVIRONMENTAL HEALTH DOES NOT HOLD ITSEL <br /> LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICA- <br /> TIONS, PLAN OMISSIONS,EXAMINATION OVER- <br /> SIGHT,CONSTRUCTION OR ANY DAMAGE THAT MAY <br /> RESULT IN OR AFTER INSTALLATION AND RESERVES <br /> THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> NK-ESSARY <br /> Attach complete plans(to the County only) or the system on paper not less than 81/2 x11 inches in size <br /> SBD-6398 (R. 01/03) <br /> I <br /> ik <br />