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■ <br /> S e.,.. au County <br /> /„$'jr;:1;:.,..N Safety and Buildings Division Dane <br /> : + U3 4,:'I�'' 201 W.Washington Ave.,P.O.Box 7162 <br /> 9 Sanitary Permit Number(to be filled in 1»'Co.) <br /> IP " Madison,WI 53707-7162 IS- ZO`�_ 00W-7-- <br /> i� T •`t <br /> •1•�;. <br /> 1ti!r.�'1 <br /> Sanitary Permit Ap.lication State Transaction Number <br /> lo accordnnce with SPS 303.21(2),Wis.Adze Code,submission o .1.,,r . • �` { t �art.-tat unit <br /> is required prior to obtaining a sanitary permit. Note Application , ,= is hied to Project Address(if different than mailing address) <br /> the Department or Safety and Professional Semiies. Personal information you provide may r• -.ndary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats Hidden View Trail <br /> I. Appli cationlnformation-PleasePrintAlllnformation <br /> ProperlyOmnerNa RECEIVED ''°"�' <br /> George& ann Klaetsch 0607-023-2056-0 <br /> Property Owner's Mailing Address Property Location <br /> 840 20th Street,#2 MAY 0 9 2016 Govt.Lot <br /> City,State Zip blic Hen th umb NW `1', SW v.. Section 2 <br /> Prairie du Sac, WI 53t/i nmental Health T 6 N; R 7 (disk <br /> I1.Type of Building(check all that apply) Lot q <br /> ]I or 2 Family Dwelling-Number of Bedrooms.4 4 1 6 Subdivision Name <br /> . ,,...._____/" Block Hidden Ridge <br /> ❑Pubiic/Comntereiol-Describe Use <br /> ❑City or • <br /> ❑State Owned-Describe Usc CSM Number ❑Village of <br /> 1 Town of Springdale <br /> III.Type of Permit: (Check only one hex on line A. Complete line B If applicable) <br /> A' ID New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only (explain) <br /> ❑Other Modification to Edsting System(explain <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POW'VTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-Grade 0 Mound>24 in.of suitable soil ®Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaUPreatment Area lnformntion: <br /> Design Flow(gpd) Design Soil Appllcnt on ate( sl) Dispersal Area'equirc3(A) Dispersal Area Proposed(st) System Elevation <br /> 600 L,', .ere if oc,("r ,.--6013- 1(t.) C 100.5' <br /> VI.Tank Info Capacity in Total IN of Manufacturer <br /> Gallons Gallons Units o i5 <br /> New Tanks Existing Tanks u o g Ti 1 § i <br /> a:er m .a n iZt e.. <br /> Septic or tickling Teak 1250 1250 1 Crest x <br /> Dosing Chamber 750 750 1 Crest x <br /> ViI.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum 's Signature L MP/MPRS Number Business Phone Number <br /> '�irt,iw 1.5 Derrn24" -�'I _ /CQrf-Y62- 412-41 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> iV`7Sbq CV( 6 w /eui r <br /> 5250g - <br /> VIII.County/Department Use Only `,1 ' <br /> Permit Fee Date ed ! Issui :Agent Si , <br /> / roved ❑Disapproved s ,r j �- <br /> I ❑Owner Given Reason for Denial r_7 (i [ ! _� y c <br /> - . <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 4 <br /> Attach to complete plans for tiro system and submit to the County only on paper not less!ban 11 12 s 11 inches in size <br /> SBD-6398(it.I I/1 I) <br />