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� ECEIVE °°°ty <br /> r/ f 1 Safety and Buildings Division Dane <br /> t 4s t ,'. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Plumber(to be filled in by Co.) <br /> •,. ,p,S.41 FEB 23 2016 Musa,,WI 53707-7162 <br /> \ Public Hral(1r MnP 13—Zo I c a_a c t) <br /> Environ a I ate TmnsactianNumber <br /> " lt�l�rmit Application . � �>, <br /> Ira acmrdunee with SPS 383.21(2),Ws.Mm.Code,submission of his tons to the appropriate '- <br /> is required prior to obtaining a sanitary penttit.Nolo Apollonian nos for state-awned POWTS are submitted to Project Address(if diRepmt.than moiling address) <br /> the Department of Safety and Professional Sce its. Personal information you provide may be used far secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stns. Eldon Way <br /> I.Application Information-Please Print All Information <br /> Property s Nome ?erect a <br /> latterman Built Homes LLC 0512-054-5644-0 <br /> Property Owner's Moiling Address Property Location <br /> 3472 Old Meier Road Govt.La <br /> City,Stale Zip Code Phone Number ''''SW rS, SE %,Section 5 <br /> Madison,WI (circle one) <br /> 606 819-0300 T 5 N; R 12 E or W <br /> Ii.Type of Building(cheek all that ap r Lot M <br /> ®I or 2 Family Dwelling-Number of:- .. 3 "-. 14 Subdivision Name <br /> • Block . v' Blue Meadow Estates <br /> ❑PublicCbmmereioi-Deseribe Use j ❑City or • <br /> ❑State Owned-Dacnbe use CSM Number 0 Village of <br /> El Town of Albion <br /> }Lterfne of Permit: (Chech.only one box on tine A.Co 'tete line B If applicable) <br /> / A' I l New System O,RepiaeemenrSystem ❑Tres.. Molding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. a of Plumber ❑Permit transfer to New t.is1 Previous Permit Number and Dare Issued <br /> .,-Q-Perm;rRlrienvl ❑Permit Revision ❑ <br /> Belom Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek• I that apply) <br /> ®Non-Pressurized la-Ground ❑Pressurirm In-Ground ❑ -Grade 0 Mound>_24 in.of suitable soil 0 Mound<24 ht.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate:(gpdsi) D. I Area Required(s0 Dispersal Arm Proposed(s0 System Elevation <br /> 450 v'0.4 '1125 Z-- 1200 94.1',94.3',94.5',94.7' <br /> VI.Tank info Capacity in Total Mot Manufacturer <br /> Gallons Gallons Units •.. a 1 k .g <br /> Nem Tanks eatstinr Tanks k ' 3 gi g <br /> c U an o, V, E O F. <br /> Septic or ltokliac Tank 1000 1000 1 Crest x <br /> moat Chaska 600 600 _ 1 Crest x <br /> Vit.Responsibility Statement-I,the understgaed,assume -...nslbtlty for installation of the PORTS sbmrn on the attached plans. <br /> Plumber's Name(Print) P 4,.-'s Signs urn ?g'MPI(S Number Business Phone Number <br /> fi e b�,i-7- E✓e r;a/7 ' I' &•4'04;1647'/ A..1-4/04- 6 08 S757 .,-90 <br /> Plumber's Address(Street.City,State,Zip Code) <br /> _CiZ err C-i.'e ev/e, 8d D t ee it 1d/'r .S3Sz5" <br /> V!1).County/De artmenf Use Only _ ' <br /> _ <br /> d ❑Dis vrd Penult F Dine Issued !scut i R""-�� ,' <br /> '' oppro <br /> ❑Owner Given Reason tar Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach In complete ohms for the nstrm ma suhmlt to the County only no paper Pat let than s tC s I 1 Inches to size <br /> SBD-6398(R_I I/11) <br />