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RECEIVED <br /> • f. `e. OCT 0 7 2015 Safety and Buildings Division• County <br /> °8"' •'�m 201 W.Washington Ave..P.O.Box 7162 smrirety peanit Momber(to he tried in by Co.) <br /> rag$ ' Public Health MDC Madison,WI 53707 7162 <br /> rivironmental Health 13-266-GO3 26 <br /> Sanitary Permit Application State Tnnanct)on Number <br /> In accordance with SPS 35331(2).Wis.Ada.Code,submission ofthis Ran to the appropriate governmental unit <br /> is regained prior to obtaining a=Mary permit.Nola Application forms for smt.awned POWIS are sal mined to Project Address(if diffetmt than mailing address) <br /> the Department of Safety and Professional Scales Personal information you provide tray be used for secondary <br /> purposes In=corder=with the Priem", w..a.15.044tpmt,Sous. Tower Drive <br /> L Application Information-Please Print AlllnfonunUori <br /> Property Owner's Name Pared* <br /> Robert&Margaret Veek 0611-252-9080-7 <br /> Property Oomer's Mailing Address Property Location. <br /> 1355 Veek Road Goes Loi <br /> Cly,Stale Zip •' P6aeNtmber SW K, NW w.swim 25 <br /> Stoughton,WI (circle one <br /> IL Type of Building(cheek all that apply) <br /> Lot II T 6 N; R 11 EorW <br /> ®i or 2 Family Dxlling-Number of. • - Subdivision Name <br /> moec# 9.6 Acre Metes&Bounds Parcel <br /> ❑PubBdCommasiel-Descraz Use ❑City or <br /> CI Sate Owned-Describe Use <br /> CSMNaarbc ❑Village of . <br /> ®Torn or Pleasant Springs <br /> iII.Type of Permit(Cheek Daly one baron line A.Complete line B if applicable) <br /> New System ❑Replacement system ❑Treotatentlliol&Lng Tank Replacement Only ❑Other Madifatimr to aiming System(=plain) <br /> B. ❑Permit Ratewal ❑Peron Revision ❑Mace.of Plumber ❑Pcrnril Tm skrt°New List"evi°us Permit Number and Date Issued <br /> Before Expansion Owns <br /> IV.Type of POW TS System/Component/Devicm(Check all that apply) <br /> ® <br /> Non•Pressurised In-Ground ❑Prr9oriad In-Ground ❑At-Grade 0 Motatd>?4 m.or suitable soil ❑Mound<24 in.of salable soil <br /> ❑Iloid'btgTadc ❑Other Dispersal Component(explain) 0 Prenmimem Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rase(gpdsf Dispersal Area Required(sat) Dispersal Area Proposed(at) System Elevation <br /> 600 0.4 1500 1500 95.0',96.0' <br /> VI.Tank Info Capacity in Total #of Mnmfmma <br /> Gallons Gallons Units o g E <br /> Nee Tads Painting Tad's > c Y 3 S 2 R <br /> o.0 cn m ED a <br /> Septic 0rli aingTassk 1000/300 1300 1 Dalmaray x <br /> Dadra clamber <br /> VIL Rosponstbtlity Statement-1,the underslgred,assume responsibility for Installed=at the POINTS Mown on the alaWed plans, <br /> Plumber's Name(Print) Plumber's S" ivrc MPIMPRS Number Business Phone Number <br /> T;rno}� 3-elte— - ),.Z 5 5 6oQ,-S3(i5 741, <br /> Plumber's Address(Street,City,State.Zip Code) <br /> Lb F� ;+Z Rd- Ve--1-0A3Gt w► 53 5C 7 <br /> tt�VIIII.Connty/Department Use Only 1,, <br /> Approved ❑Disapproved nGi 5// 9� f issued Isu��3uLp;t Stg)t} <br /> ❑Owmx•Gvm Reason for Denial 7/{1 0-$-20/s FI®�// <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Anscb to complete piss for du syatea a=sobatt to the Coat}only to paper not less dm a 14 r n taekn le size <br /> SBD-6398(R.11/11) <br /> I <br />