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I. xR;/�� „, . lR '�YMsion County <br /> rf DANE <br /> �,•: 451/ <br /> ! 1400 E.Washingt• �' a .HIV E D Sanitary Permit Number(to be filled in by Co.) <br /> \ � IV 3Fl n.r t s-0o3418 <br /> DEC-2 8105 i3—l� <br /> Sanitary Permit Application State Transaction Number <br /> In acoaoo <br /> dee with SPS 36321(2),Wis.Aden Coda arbmissioo of this form to the app��jp bn al l <br /> is required prior to obtaining a sentry permit.Note:Application forts for sullcowo ere <br /> su t <br /> the Department of Safety and Professional Servirs Personal information you provide may be need for secondary Project Address(if different than mailing address) <br /> praposea in accordance with the Privacy Law,s.IS.04(Ikm),Suds. <br /> L Application Information-Please Print All Information CTH B <br /> Property Owner's Name Parcel# <br /> JASON SCHLIECKAU 0612-203-8835-0 <br /> Property Owner's Mailing Address Property,Location <br /> W9202D RIPLEY RD. NW r%, SW % Section 20 <br /> City, State, Zip Code Phone Number <br /> CAMBRIDGE,WI 53523 608 469-5680 T 6 N,R 12 E <br /> Il.Type of Building(check all that apply) Lot# 1 Subdivision Name <br /> L9<2 Family Dwelling-Number of Bedrooms 4 Block# <br /> 0 Public/Commercial-Describe Use CSM Number 0 City of <br /> 0 State Owned-pest°be Use 11876 D village of <br /> tg'lownof CHRISTIANA <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> t' I &New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> $' i 0 Permit Renewal 0 Permit Revision 0 C anger of Plumber ❑Permit Transfer to <br /> List Previous Permit Number and Date Issued <br /> Before Expiration L New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) • <br /> 7/on-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 is of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) Pretreatment Device(explain): <br /> V.DispersaVTreatmeat Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area Required(sf) [Disposal Area Proposed(st) System Elevation <br /> 600 0.4 1500 1512 96.7' <br /> VI.Tank Info Capacity in I Total #of Manufacturer <br /> Gallons I Gallons Units o a <br /> New Tanks Existing Tanks v U .. a <br /> I L' E _Y .1 i m <br /> n. :J y v y u. ci O., <br /> Septic or Adding Tank 1250 1250 1 DALMARAY _ X <br /> Dig Chamber 250 75o 1 DALMARAY X <br /> VIL Responsibility Statement-1,the undersigned,assume res nsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) !um_ 's Si MP/MPRS Number 1 Business Phone Number <br /> SCOTT LOVELACE 226-852 (608)465-3314 <br /> Plumber's Address(Sweet City,S ) <br /> LOVELACE PUMP COMPANY,INC..9914 COUNTY M.ARGYLE.WI 53504 <br /> �VIIIIII.Conn /Department Use Only <br /> 0C�+PP�ed ❑Disapproved Permit Fa Date i Issui , rr !'n �i / <br /> t ❑Owns Given Reason for Denial <br /> $ / 2q /5 '� ���IP' 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Mach to complete plans for the system and submit to the County only on paper not less than 8 1/l x 11 inches in size <br /> SBD-6395(R 0313) <br />