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, ..u ,r, RECEIVEDty <br /> ;s f r ,. 4, r'i Industry Services Division FEB 2 3 2016 DANE izi <br /> 1400 E.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t\`.. '% Madison, WI 53707-7162 Public Health MDC <br /> `'`"`� Environmental Health IS- Zo I b - 00°35- <br /> Sanitary Permit Application ! ; State Transaction Number_, <br /> NED <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropn goe <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-otivned POWTS re submme o <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information PERRY CENTER RD. <br /> Property Owner's Name Parcel# <br /> 4,---TREVOR &CHELSEA RUNKLE c/o ,4..0506-263-9000-3 <br /> Property Owner's Mailing Address Property Location <br /> JG DEVELOPMENT,4070 E. BRIGHAM RD. &.--SW r/<, SW /4, Section 26 <br /> City, State, Zip Code Phone Number <br /> BLUE MOUNDS, WI 53517 608 576-7850 T 5 N,R 6 E <br /> H.Type of Building(check all that apply) ' ---- ~ N., Lot# Subdivision Name <br /> El or 2 Family Dwelling-Number of Bedrooms 4 1 Block 4 <br /> ❑Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use ❑Village of <br /> town of PERRY <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. CN'New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: heck all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Groun Ls1'At-Grade C'Mound>-24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain ---._.. - 0 Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) 1 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 ,lam'-0.6 _ �''' 1000 1010 100.3' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units =' •o <br /> o <br /> New Tanks Existing Tanks u c 4) = y s 2 <br /> c. U 'tit N :n is. 0 <br /> Septic or Holding Tank 1250 1250 1 DALMARAY X <br /> Dosing Chamber 750 750 1 DALMARAY X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) fturmtt,r's Signal MP/MPRS Number Business Phone Number <br /> SCOTT LOVELACE __ - d,,,,e --'-a ' 226-852 (608)465-3314 <br /> Plumber's Address(Street,City,State,Lip Code) ---.- <br /> LOVELACE PUMP COMPANY, INC., 9914 COUNTY M, ARGYLE, WI 53504 <br /> �VIIII.County/Department Use Only , • <br /> improved ❑Disapproved Permit Fee O� Date Issued ,•`rJ Issuin��/ •;. 1 <br /> r \ ❑Owner Given Reason for Denial $ k I'2p / - �1If <br /> IX.Conditions of Approval/Reasons for Disapproval �t -► <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I 1 inches in size <br /> SBD-6398(R.08/14) <br />