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County ^� <br /> / i:. Safety and Buildings Division Dane l_) <br /> 1g ii ,' 201 W.Washington AVe.,P.O.Box 7162 S y Pay Number(to be Bled in by Co.) <br /> ' tit Madison,WI 53707-7162 <br /> ; arms. \ 26s c l <br /> Sanitary Permit Application StacTrmwntonNumber <br /> to accordance with SPS 31321(2).Win Adm.Code,submission of thin lean to the appropriate governmentol unit <br /> Is required prior to obtaining a wiry pen it Note Applicata'bats for sto&e•ansd rows are submitted in Project Acidness(irdiifecag than mailing address) <br /> the Department of Safely and Professional Soaks. Personaliafartombn you provide nary be used for secondry <br /> purposes in accordance with the Priem Law,s 15.04(I)(mt.Sku. 5320 Cuba Valley Road <br /> I.Application infer.malion-Please Print AB Information <br /> Property Owner's Nam Parcel 9QOS-0 <br /> Jack Jenney Wendtland 0909-2749569-1- <br /> Property Owner's Mailing Address • Properly Location <br /> 5037 Daley Road poylta <br /> City.State rip Cede PhoneNumber • SE <br /> Deforest,WI 53532 358-8865 SE st`s on 27 <br /> II.Type of Building(check all that apply) tot g T 9 N; R 9 E a W <br /> ®I or Fame Dwelling-Number of Bedrooms 4 1 Subdivision Nam <br /> Block N <br /> ❑Pub1e/Canmerciel-Describe Use ❑City of • <br /> ❑State Owned-Describe use CSM Number ❑Village of <br /> Proposed 1 Town or Vienna <br /> Ill.Type of Permit: (Check only one box on line A.Complete Rae B If applicable) <br /> li" ®New System ❑Replacement System ❑Tre nneat/Holding Teak Replacanem Only ❑Other Modification to Existing system(napkin) <br /> B. ❑Pamh Renewal ❑Peimh Revision ❑ us'Previous Penn"Number and Dale Issued <br /> Meow-another ❑Ponmb Transfer to Now <br /> Before Expiration Owner <br /> IV.Tyne of POWTS System/Component/Devica (Check all that apply) <br /> J Non-Presseriard tn•Oraad ❑Pressurized la•Groo d ❑At-Grade ❑Monad x.24 in.of suitable sal ❑Maud<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(=akin) <br /> V.DtspersaUfreatm eat Area Information: <br /> Design Flow(gad) Design Soil Application Rah(gpdsq Disposal Ares Required(so Dispersal Area Proposed(sr) System Elevation <br /> 600 0.4 1500 1512 97.2,97.8,98.4,99.0' <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Cottons Gallons Units i 6 u' .2 <br /> Now'links Patina Tonto },u <br /> U 'w$i 11 O a <br /> Sepik or Hvldig Took 1200 1200 1 Meade x <br /> Dosing Clamber 800 800 1 Meade x <br /> VII.Responsibility Statement-I,the urdersigaed,assume responsibility for brstogaloa of the POSITS shown on the attached plans. <br /> Plumber's Name Pkarier' S MP/MPRS Number Bvskes Phone Number <br /> pier r .�`t "C l �?'°� `_ X31?�R �'f (//�3 <br /> s Address( reel tly,State.Zip Code) (,e �/J q I � // <br /> VIII.Co naty em�nlye 4 11.f A t 1 l i t i W 6 ;t5q <br /> "'""" ❑Disapproved t],P(ee� Dote issued Issuing ISigmture <br /> ❑owner Given Reason for Denial orq\)l. /o-82-/s� ,n., <br /> LX.Conditions of Approval/Reasons for Disapproval <br /> Attack to aapkle ploys for Ow worm and submit to tae Comfy sob•OR paper not less Ilan a m a t 1 loft=to dm <br /> eivv4-11 -1,, t49-- f o ,�ck �►€ /aQ ( CS_WM <br /> SBD-6398(R.I I/1 I) J <br />