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/o-,41w? (n _E U, ,ry I County . <br /> ''/ a \}".\ ' Safety and Buildings Division DANE <br /> :?3°d d � <br /> 28.j vv. shington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) • <br /> \:k,4\:....0:41..'` " on,WI 53707-7162 /2_a0i� pt13 •6 <br /> . /✓ <br /> ff I <br /> 1 rarutar, ?e zt' A' Ophcation iState Transaction Number <br /> In accordance with SPS 38321(2),Wit.Adm•Code.submiu this form to the appropriate governmental unit ------- <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to • <br /> the Department of Safety and Professional Service.Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information I SAME <br /> Property Owner's Name • Parcel# <br /> JEFFREY&MELISSA SINGER 0608-284-8930-9 .I <br /> Property Owner's Mailing Address [Property Location <br /> 2005 STATE HWY 69 II NW''V., SE /. Section 28 <br /> City, State, Zip Code Phone Number I i <br /> VERONA,WI 53593 -Z--\ 608 848-4870 i T 6 N,R 8 E <br /> II.Type of Building(check all that apply) Lot S Subdivision Name <br /> 1B or 2 Family Dwelling—Number of Bedrooms 3 (Block t ' <br /> 0 Public/Commercial—Describe Use ICSM Number 0 City of <br /> I❑State Owned—Describe Use ❑Village of <br /> ty'fown of VERONA <br /> (III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I 0 New system +(7 Kcplacement System f 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I li <br /> 1 <br /> 18- ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration . New Owner I <br /> IV.Type of POWTS System/ComponentlDevice: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade to Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) 1 Dispersal Area Proposed(sf) I System Elevation <br /> 450 0.6 750 I 833 199.2' <br /> VI.Tank Info Capacity in Total I ft of Manufacturer <br /> _ �1.1 <br /> Gallons I Gallons I Units � c B U <br /> New Tanks I Existing Tanks I I •I. m 8 w TO A o i <br /> e_ U o rn v. U <br /> Septic or Holding Tank 1000 I 1000 I 1 DALMARAY 1. X • <br /> Dosing Chamber 600 • I ' 600 I 1 I DALMARAY j X I I I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) • 1 Plumber's Sig�nnaa.ly4re �,��i�1� MP/MPRS Number Business Phone Number <br /> TIMOTHYJELLE I r Lriots�'u.r �° '� 227-525 (608)845-7466 <br /> Plumber's Address(Street,City,State,Zip Code) �� <br /> VERONA SEPTIC AND EXCAVATING,1330 FRITZ ROAD,VERONA,WI 53593 <br /> 'VIII.County/Department Use Only <br /> ( Approved I ❑Disapproved Permit Fee ssued I Issut ent Si <br /> I� I l7 Owner Given Reason for Denial IS /a . — lb/12 <br /> 101(3 I / -�� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ex t s .s- s 51k-s t_ Ple1 LT 4.-- 6-c_ fo we,p--e-,1[ 0,b 0^-4 <br /> a-s _ C-0-etc <br /> (/ Anach-to complete plans for the system and submit la the County only on paper not less than 8 12 s 11 inches in size <br /> B 1 98(R.11(1-e9.L 051- • <br />