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/ * Safety and Buildings Division County Dane \:,---Thi <br /> ;¢t/ .. 201 W.Washington O.Box 7162 <br /> nstz`�'�:t' "` 9 Ave.,� Sanilary Pertnit Number(tobe filled inbyCo.) <br /> i,. •;1;4;; fi n WI 53747-7162 <br /> ; - 1 . <br /> Sanitary Permit Ap"' icatie;~ W State Transact ion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this faun to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Protect Address(if different than mailing address) <br /> the Department of Safety and Professional Scrvies. Personal Information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Silts. CTH A <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ' Don &Janice Bates ' ' <br /> - 0510-134-8200-0 <br /> Property Owner's Moiling Address Property Location <br /> 809 Bergen Court Govt Lot <br /> City,State Zip Code Phone Number �,,.-.-NE r,,, SE '/+, Section 13 <br /> Stoughton, WI :9 (circle one) <br /> 11.Type of Building(cheek all that apply) -Th Lot# T 5 N; R 10 E or W <br /> ®I or 2 Family Dwelling-Number of Bedroot 3 1 Subdivision Noma <br /> 111 Bioek <br /> ❑Public/Commercial-Denai.71 —" <br /> ❑City or • <br /> ❑Slate Owned-Describe Use APR 2016 CSM Number ❑Village of <br /> %.-'I 127 ®Town or 4... <br /> III.Type of Permit: (Check only t p11o,'titetll11 MQCCom lete line B if applicable) <br /> A" y ❑f t.•hiEittSyg'iltatt IAcBl 11 g Replacement Only <br /> New System em TreWment/ilolc in Tank R ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expitaiion Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> IN Non-Pressurized In-Ground ❑Pressurized Ire-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<14 in.of suitable soil <br /> ❑holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soll.Application Itate(gpds1) Dispersal Area Required(si) Dispersal.Area Proposed(Al) System Elevation <br /> ` ' 450 U` 0.7 I-" 643 ' 900 92.9'&93.2' <br /> VI,Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o T1 At.) <br /> • <br /> Now Tanks Existing Tanks u 8 s 3 a <br /> 0 <br /> c`.0 tA� h r:.tJ F. <br /> Septic or Holding rmtk 1000 1000 1 Dalmaray x <br /> Dosing chamber 600 . 600 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume respond!) • •for installation of the POWTS shown on the attached plans. <br /> ! s Name P' -'s St.Mt(tre MP/MPRS Number Business Phone Number <br /> ` � _ \ C ` . & 873-792- <br /> Plumber's Address Street.City,State,Zip Code) \ <br /> VIII.County/Department Use Only - ----' , I <br /> Approved ❑Disapproved S Fie /Dal1t ed Issuil A plSigliat❑Owner Given Reason for Denial . �"f• /�, �j/- 1 - —_--� <br /> I`X.Conditions of Approval/Rensons for Disnpprova( ' ` <br /> • <br /> Attach to complete pions for the system nmut submit to the County onty an paper not less than S to s II Inches In size <br /> SBD-6398(R.11/11) <br />