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igp- Courtly <br /> /.art .. `4,1 Safety and Buildings Division Dane <br /> f il,A 201 W.Washington Ave.,P.O.Box 7162 Smfiary Permit Number(to be filled in by Co.) <br /> $it S- �I Madison,WI 53707-7162 <br /> I 3-2.1itD—(i co2� <br /> Sanitary Permit Application State Transaction Number <br /> la accordance with SPS 383.21(2).Wis.Adm.Code,submission of obis form to Me appropriate governmental unit <br /> is regoised prior to obtaining a sanitary pamll Note Application fonds for slate-owned POWIS are submitted to Project Address(if different time mailing address) <br /> the Department of Safety and Professional Serries. Personal information you provide may be used for secondary <br /> proposes in accordance with 14e Privacy law,s.15.84(11(ml.Stars. _ Hidden Ridge Trail <br /> L Application Information—Please Print MI Information <br /> P`O y Omni s Nome Parcel A <br /> !/ Stendalen Living Trust(Jason&Abby Stendalen) '607-023-2067-0 <br /> Property Owner's Mailing Address Property Locution <br /> 5430 Yesterday Drive Govt Lot <br /> City,State Zip Cede Phone Number NW IS, SW 1S,Section 2 <br /> Madison,WI z 18 (circle erne) <br /> 11.Type of Building(cheek all that apply) Lot 8 T 6 N; R 7 Ear W <br /> ®I or 2 Family Dwelling-Number of Bedrooms 4 Subdiv an Name <br /> Block' Hidden Ridge <br /> ❑Publc/Commercinl-Descwlbe Use ..- <br /> ❑City of <br /> ❑Stoic Owned-Describe Use CSM Number ❑Villager of <br /> O <br /> El Town of Springdale <br /> • <br /> ill.Type of Permit: (Check only one box on line A.Complete line B If applicable) <br /> A'. i New System ❑Replacement System ❑TreatmenUkloldlog Took Replacement Only ❑Other Modlncatlon to Existing System(=plain) <br /> Lin <br /> R. ❑Permit Renewal ❑Pennil Revision ❑Change of Plumber ❑Permit Transfer to New Previous Pamil Number and Dale Issued <br /> Derma Expiration Owner <br /> IV.Type of POWTS System/Component/Device:(Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil Mourd 24 to.n(uitabme null <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dtspernallfreatment Area Information: <br /> Design Flow(god) Design Soil App!' ion Ratetypdsl) Dispersal Area Required(st) Dispersal Ares Proposed(st)i System Elevation <br /> 600 A( ire,--- 9rf 1042' <br /> VI.Tank Info Capacity in Total Hof Manufacturer z , <br /> Gallons Gallons Units r <br /> New Tends Fames Tmkn t" u 3 ,g 2 .B <br /> n`o <br /> �v ", H ei:o o. <br /> Septic or Holding Tank 1250 1250 1 Crest x <br /> WAWA Chamber 750 750 1 Crest x <br /> VIL Responsibility Statement-1,the undersigned,assume nsibtRty for Installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's tare MP/MPRS Number Bushress Phone Number <br /> �cc 0QS ) ?,r /c'2c, r2 '/Z y-301( <br /> Plumber's Address(Street,City.State,Zip Code) <br /> 417869 C-.fr Q 7?,/‘.,,,,/c 6,L 5' . <br /> VIIL Counh/Do.ailment Use On)r i <br /> yr l'.Approved ❑Disapproved Permit Fee(' Data --�/-� Y' /�'. <br /> 0 Owner Given Reason for Denial S I r 24 W /!flifilWAILv <br /> � I\.. <br /> IX.Conditions°I-Approval/Reasons for Disapproval l . <br /> Attach to mmpkte pbms for the syram and mhtatt In the County only an paper not less than I tO s 11 neha in she <br /> SBD-6398(R.I I/1 I) <br />