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RECEIVED <br /> DEC 16 in county <br /> l,��;f*� '.N Safety and Buildings Division Dane <br /> ,f17 p.� ..,>z; Public Health M �n1 W.Was <br /> Ave., .O.Box 7'162 <br /> 'r: r`g p x' Fl Environmental ealiTl t �'' smtlmty Permit Number(to be Oiled bt by Cc) <br /> i' .. 5 sr Madison,Wt 53TO7 7162 <br /> .,, 13 -201. ----60372_ <br /> Sanitary Permit Application StateTeartsactionNUmber <br /> In accordance with SPS 383.21(2),Wis.Aden Code,submission of this form to theappropriate governmental unit <br /> is requited priorio obtaining a sanitary;:mil Note:Application forms for state-owned POW]S are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Series. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.IS.t)4(I)(m),Slats. Old Stage Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name. Pared.# 0510-294-8020-0 <br /> Mark&Kerry Copus <br /> Property Owner's Mailing Address Property Location <br /> 240 US Highway 14 Govt,Lot <br /> City,Stale rlp Cede Phone Number NE vs SE %,Section 29 <br /> Brooklyn,WI --43521 608-445-0598 5 (citaleone) <br /> H.Type of Building(check all that apply) Lot# T N; R 10 E or W <br /> El I or 2 Family Dwelling-Number of 4 / 1 Subdivision Name <br /> Block* <br /> Q Publk/Commercial-Describe Use <br /> 0 City of <br /> Q State Owned-Describe Use CSM Number 0 Village of <br /> 14078 El Town or Rutland <br /> Ili.Type of Permit (Check only one box on line A. Complete line B If applicable) <br /> A' ®.New System 0 Replacement System 0 TrmimenNldokEngTank Replacement Only 0 Other Modification to Existing System(explain) <br /> D. 0 Permit Renewal ❑Permit Revision Q Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS System/Component/Device: (Check all that apply) <br /> IN Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.ofmitabk soil ❑Mound<24 in.of suitable soil <br /> Q Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dlspersalftreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratdgpdsl) Dispersal Area Required(si) Dispersal Area Proposed(si) System Elevation <br /> 600 0.4 1500 1512 96.0' <br /> Vl.Tank Iola Capacity.in ` Total Nor Manufacturer a a o� <br /> Gallons Gallons Units a u m <br /> New Tanks Existing Tanks I. .a 1 g .g § ;3 <br /> a.U ,-,-1 w ta r:tJ i% <br /> Septic or atamogTaalr 1250 — 1250 1 Crest x <br /> Owing Chamber 750 _ 750 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of time POWfS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature )t0/MPRS Nwnber Business Phone Number <br /> gobee-t .ve-r`54/1 l )4 l , 7 a-a4// 6 ee-53..5-7' / <br /> Plumber's Address(Street,City,State,Zip Coddee)/ <br /> _�V,I/II.Connty/Department Use Only <br /> '<Approved 0 Disapproved Permit Fee Date)sued Issuing Signal <br /> Q Owner Given Reason for Denial 3 y.7/ 12—PT-20/S— / C -A//1/tg;—\ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> } <br /> \, <br /> Attach to complete plans for the system mat submit to the County only an paper not less than S to s Mucks Inks to size <br /> SBD-6398(IL 11111) <br /> • <br />