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County <br /> t<45'iti Safety and Buildings Division Dane ./tG <br /> t .'4 i is..A 201 W.Washington Ave.,P.O.Box 7162 Soldiery Permit Number(to be Shed in by Co.) <br /> 'D�r:c I*1 <br /> i•1 15,..1-w' 4/ Matflson,Wt 53707-7162 _ <br /> Sanitary Permit Application Stott Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Nett Application firms for state-owned POWTSare submitted_to Project Address(if diWcrent than mailing address) <br /> the Department of Safety and Professional Salim. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law.s.15.04(1 Xm),slats. 6610 Sun Valley Parkway <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Knight Family Farm LLC 0508-024-9500-3 <br /> Property Owner's Mailing Address Property Location <br /> 6420 Sunset Drive Govt.LW <br /> City,State • Zip.Cade Phone Number SE is, SE ttA,section 2 <br /> Verona,WI �'53593 (circle one) <br /> H.Type of Building(check all that apply) <br /> 1 Loup T 5 N; R 8 E or W <br /> ®1 of 2 Family Dwelling–Number of Bedrooms�4 M ' Subdivisitm Nodes <br /> Block 36.6 Acre Metes&Bounds Parcel <br /> ■ ❑Public/Commercial–Describe Use ❑City of <br /> ❑State Owned Describe Usc CSM Number ❑Village of .. <br /> lg Town of Montrose <br /> ID.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) ' <br /> B. 0 Permit Renewal 0 Permit Revision 0 Omega of Number 0.Pnnit Transfer toNew List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV Type of POWTS System/Component/Device (Check all that apply) <br /> Non-Presssirized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Moond?24 in.ofsuitnble soil ❑Mound<24 hr.of suitable soil X❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(=plain) <br /> V.Dispersal/Treatment Area information; <br /> Design Flow(gpd) Design Soil Application Ilate(gpdsl) Dispersal Area Required Id) Dispersal Area Proposed isi) System Elevation <br /> 600 .„9..5 C ,—7 MOO— 57 1200 96.5',98.0' <br /> VI.Tank Info Capacity <br /> {d in GaTotal wns Units Manuraclurer er <br /> o <br /> New Tanks Existing Tanks E c 3 1 $i .� <br /> a`U en.w £ rTO a <br /> Septic or Holding Teak 700/550 1250 1 Crest X <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assn a responsibility for installation of the COATS shown on the attacked plans. <br /> Plumber's Name(Print) Ku • Signature MP!MPRSNumber Business Phone Number <br /> Try lt)' o5-2- -1/'2 .(--50/9 <br /> Plumber's Address(Street,City,State Zip Code) <br /> . )7'17609 ( e /3e1"°zert6 x- 35O) <br /> VI County/Department Use Only <br /> xll. <br /> Approved ❑Disapproved <br /> :lit Fee ....... Damissuued r'C Issui we <br /> ❑Owner Goren Beason for Denial �� -/Y 17 — <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> \..... <br /> I <br /> ' Attach to complete plans for the system had submit to the County only on paper oat has 8 tax t 1 who la size <br /> SBD-6398(R_l 1/11) <br /> • <br />