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..< n�:iti.; County <br /> /i1'::':x,. 'es Safety and Buildings Division Dane <br /> /air..f ,` 201 W.Washington Ave,P.O.Box 7162 Sanitary Permit Number(to be lilted in by Co.) <br /> t t SPS""s/� Madison,WI 53707-71620 <br /> Sanitary Permit Application State Transaction Number <br /> in accordance with SPS 36321(2),Wis.Mm.Code,submission of this font to the appropriate gotrmmentol unit <br /> is required prior to obtaining a sanitary permiL Now Application forms for stale-owned POttrrS are submitted to Project Address(it different than mailing address) <br /> the Department of Safety and Professional Seme. Personal)nfonresicit oa provide may be used for secondary <br /> purposes in oceordance with the Privacy taw,s.15.04(1 Nm1.Stets. ��E EI V <br /> T / Lally Road <br /> I.Application Information-Please Print All information <br /> Properly Owner's Nome Parent 4 <br /> Darin Oler MAR 0 8 Mt 0610-281-8850-4 <br /> Property Owner's Mailing Address Property Location <br /> 4056 Lally Road Public Berlin MDC Govt.La <br /> City,State Zip Code EnAttagogAigal Health NW:� NE%.Section 28 <br /> Oregon,WI 53575 347-4407 6 (circle one) <br /> Ii.Type of Building(check all that apply) Lot 8 T N; rt 10 E a w <br /> ®I or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Nome <br /> Block d <br /> ❑Publk/Coinmereial-Describe Use ❑City of • <br /> ❑Slate Owned-Describe Use CSM Number ❑Village of <br /> 2178 a Town or Dunn <br /> iIi.Type or Permit: (Check only one ham on line A.Complete line B if applicable) <br /> A' ®New System ❑Replacement System ❑Treatment/HoldingTank Replacement Only ❑Other Modiftation to Existing System(explain) <br /> R. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transkr to New List Previous Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type orPOWTS System/Component/Device: (Check all that apply) <br /> IN Non-Pressurized to-Ground ❑Pressurized In-Ground ❑At-Grade ❑Monnd>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Took ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Iorormntlon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(so Disposal Ares Proposed(aq System Elevntion <br /> 600 0.4 1500 1512 94.0',94.7',95.4' <br /> VI.Tank lafo Capacity in Total if of ManuIucturee <br /> Gallons Gallons Units e <br /> ,6 u <br /> 3 .2 <br /> Ness Tanks E iminr Tanks V ac 2 t ] 1 d 8 <br /> V H u, m i=O E. <br /> Septic or Holding Task 1250 1250 1 Crest x <br /> Dosing Chamber 750 750 1 Crest X <br /> VII.Responsibility Statement-I,Ilte undersigned,assume responsibility for installation of the POSVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature ivitlYMPRS Number Business Phone Number <br /> i'01,0-7-- t'1'6rsol> 0e=1-74"S n ,z;-4// 6G�ss s'7s-4";Ii/ <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> 5,,2 .5 L-a k zL ,'/kr 4'd C,v-ee,>L 41// .f.75 <br /> VIII.County/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee Dole issued issuing Agent Signature <br /> S <br /> ❑Owner Given Reason for Denial <br /> IX Conditions or Approval/Bensons for Disapproval <br /> Attach to complete plans far the system soul submit to the County only an papa sal lea than 8 ICs II inches le she <br /> SBD-6398(It.I I/1 I) <br />