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Safety and Buildings Division Dane ® � _ i' <br /> v.-- ty <br /> 201 W.Washington Ave.,P.O.Box 7162 County <br /> ■seOnsin Madison,8) 6-315-7162 Sanitary Permit Number(to be fitted in by Co.) <br /> (608)266 3151 <br /> L�Salt,�l� <br /> Department of Commerce State PlanLD_Number <br /> Permit Application �'' <br /> Sanitary �`' _ <br /> " In accord with Comm 83-21,Wis.Adm.Code,personal information you provide (if different than mailing address) <br /> �y be used for secondary purposes Privacy Law,s 15.04(lxm) <br /> Project Address <br /> Washington Rd <br /> I. Application Information-Please Print All Information Parcel# dot# Block# <br /> Property Owner's Name 046-0611-254-9691-0 <br /> Mike&Colleen Holtan Property Location <br /> Property owner's Mailing Address $E yS S E %, Section 25 <br /> 4710 Sycamore Avenue Phone Number <br /> Zip Code 11 (circle one) <br /> City,State 53704 243-9624 T 6 N� R ir a W <br /> Madison,WI <br /> Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) 4 Lot 1 CSM 10726 <br /> Ei 1 or 2 Family Dwelling-Number of Bedrooms <br /> 0 Public/Commercial_Describe Use ■ . Dyt]]agenT°w°ship°fPl. Springs <br /> ❑State owned-Describe Use 'A <br /> Type of Permit: (Check only one box on line A. Complete line B if applicable) JILL ' n <br /> �.Z.Yp y J�'�� ��::n,C, �' <br /> NI fl New System ❑Replacement System <br /> ❑Treatment/Holding Tank Replacement Only finiri ' E � , <br /> �!• aps Permit Num - n- jy <br /> I ❑Permit Revision 0 Loge of ❑Permit Transfer to N t/ f I <br /> 0 Permit Renewal Plumber Owner O .ill <br /> Before F�cpiratioo � /////� <br /> of POWTS S : em: Check ail that ' ' n ' «� <br /> IV.T'/' <24 in.of suitable soil II , '•;14 7: �p k�i " L <br /> C Non-Pressurr�dL°In-Ground <br /> ❑Mound>24 in.of suitable soil 0 Mond Bp. QI:Tank ❑Peat Filter 0 Aerobic Treatment Unit ■ ": " <br /> Constructed Wetland ❑Pressurized In-Ground ❑Holding 0 Drip line ❑Gravel-less Pipe ❑Other(....lain) � <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber Ate��(� System��� <br /> D.Design Flow(gpd) Design Soil Info li tion Rif) Dispersal Area Requited(sf) Dispersat 93.0,93.5,94.0'a Elevation <br /> on <br /> Design Flow(� Design Soil A4p 1500 1512 <br /> 600 0.4 Prefab <br /> Site Fiber Plastic <br /> Total Number Manufacturer Concrete ConSinrcted Glass <br /> VI.Tank Info ��1° Gallons of Units <br /> Tanta , - ©--_IIIIII <br /> iiiiiiiaiiill Iiiillailill 1250 �r�rav MMIIIIIIIIIIIIIIIIIIIIIIIM_ <br /> Doering Ctd <br /> 75° 75° v shown on the attached plans. <br /> assume responsibility for installation of the POWIS Phone Number <br /> VII.Responsibility Nam (Print)Statement-I,the undersigned,bees i • _I" `Number <br /> Plumber's sign ��o g�3—.SO bY� <br /> Plumber's Name(Print) / ga3 al a fs <br /> Plumber's (Street,City, <br /> q` - 14.1,0 4. � , `e J rt, tAi i 53581 A <br /> __�"� (rl°stamps) <br /> Da Issued S'% <br /> VIII.Conn /De artment Use O ,Permit Fee includes Groundwater ,��I r 7 <br /> ❑Disapproved Surcharge Fee) 31 c i /c/d 4 ,Lkl'��l1i�i ' <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br />