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1 qr. Ni <br /> • Safety and Buildings Division County <br /> �� 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> N rsconsin Madison,1)266-3151 53707-7162 <br /> 8)(60 'Sammy P (to be filled in by Co-) <br /> ' , Department of Commerce <br /> (435arto C" -00 <br /> Sanitary Permit Application Plan LD.N <br /> In accord with Comm 83.21,Wis.Adm.Code,pasosai infotmotioe you provide <br /> may be used for secooda y papaw Privacy Law,s15.04(lXm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information Welford Place <br /> Property OwOer's Name Parcel# Lot N FL- J Black M <br /> Peter&Jennifer Simon 012-0911-183-024 <br /> Property Owner's Mailing Address Property Location <br /> 2780 Brooks Ridge Drive _ NE <br /> City,State Tip Code Phone Number Y., SW V4,Section 18 <br /> Sun Prairie,WI 53590 <br /> 9 11 (circle ease) <br /> T N; R Saw <br /> IL Type of Building(check all that apply) � <br /> Fn 1 or 2 Family Dwelling-Number of Bedrooms ' +'_ /✓ Subdivides Name CSM Number <br /> Lot 23 Winfield Estates <br /> ❑Pub&&onunarcial-Describe Use <br /> ❑State Owned-Describe Use bty DVi lage fl township orBristol <br /> m. heck only one boa on ties A. Complete We B If glplicable) <br /> New System ❑Replacement System ❑1Yeatmmf/Holding Tank Replacement Only ❑Ol Modification to Existing System <br /> ListPre�'�Permit Number and Date belied B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit-Ilrmsfer to Nerty C."' <br /> IV Cheek all that :, owe `Y 0 ✓� '/ <br /> ,w t .,, , ❑Mound>24 in.of suitable soil ❑Mound<24 in.of ndlable soil ❑At-Osde ❑Single Pea$fn9 filler ❑ <br /> .•- 11 Pressurized In-Ground ❑Holding Task ❑Pat Filter ❑Aeubie Trntment Usk ❑Rem salad,Filter /0 <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip fine ❑(baud-lax Pipe ❑Other(explain) <br /> V.DispersaVfreataeat Area Information: j <br /> n <br /> Dodge Flow(gpd) I Design Soil Application Rate(gpdsf) Disposal Amer P rp ed(if) I Dispersal Ares Propaod(d) ' Spann Elevation <br /> 600 0.4 1500 1512 97.0,98.3,99.5' <br /> VI.Tank Info Capacity in Total -Number Mmofactuta - Prefab Site Steel Fiber er Plastic <br /> Gallons Gallons of Units Concrete Constructed I Glass <br /> New & i <br /> - Tasb Taub <br /> Sgtio or HoMdq Took 1250 1250 1 Crest x <br /> • <br /> Amebic Trommem unit <br /> Dodos umber 750 750 1 Crest x <br /> VII.Responsibility Statement-1,the odersigaed,asame respoadliWty for iastalalisa of the POW'I'S drawn w the attached plus. <br /> 'a Name(Print) `' s Si t MP/MPRS Number I Business Phone Number l <br /> o��.+ rvo,.eI � a 7,-7 i hog 97j P902 <br /> Phmber's Address(Street,City,State,Zip Cade) <br /> k D r., <br /> rYsv as ,0' . �-. = s- <br /> VIII.Coaatty/l epartineat Use Oaly v ✓ ' <br /> I Sanitary Permit Fes(includes Groundwater Date r ,,.., Agat S._ _�• 1 <br /> ❑Owner Given Reason for Denial Surcharge Fee) Ici5- J I ' I / v' ig <br /> IX.Conditions of ApprovaVRessons for Disapproval <br /> -Attach complete plans(to the County only)for the system oo per mot len Manila x 11 tacks in sin <br /> SBD-6398(R.01/03) <br />