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County <br /> / _ Safety and Buildings Division Dane <br /> f1r '`1 ? ' 2D1 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Cu) <br /> ;3 �S=p4 i Madison,Wi 53707-7162 <br /> v .s; - - 2 <br /> � .yr <br /> 1 2 / U / <br /> Number <br /> Sanitary Permit Application State Tn muu�tioit <br /> In accordance with SPS Mai(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note Application fors for state-owned POWTS are submlticd to Project Address(if different than mailing address) <br /> tfie Deputrinicnt of Safety and Professional Servies. Personal information mu provide may be used for secondary <br /> purposes in accordance with Ike Privacy Law,s.15.04(1 kmi, E T v <br /> /E D <br /> I. ApplicationInfarinatlon-PleasePrintAlllnfos- <br /> Property Owner's Name Puree) <br /> Mike&Laura Knipfer JAN 2 5 2016 0711-133-9780-2 <br /> -Property Owner's Mailing Address Property Location <br /> 1770 N. Jargo Road public Health MDC <br /> nvironm� Govt.Lot <br /> City,Stale Zip t e -Fiii SE 'd. SW S:,section 13 <br /> Deerfield, WI 53531 712-7531 T 7 pd, pt 11(circle w <br /> 11.Type of Building(check all that apply) Lot 0 <br /> ®1 or2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> Block 18.26 Acre Metes&Bounds Parcel <br /> ❑Public/Corunerciat-Describe Use ❑City of - <br /> CSt+I Number ❑Village of <br /> ❑State Owned-Descnbe Use ®Tosrn of Cottage Grove <br /> iii Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ®New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of-plumber 0 Permit Transfer to Nna <br /> List Previous Permit Number sad Dale issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Couiponent/Devhxt (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground CI At-Grade 0 Mound,.24 in.of astable soil Q Mound<24_in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area information: <br /> Design Flaw(rte) Design Soil Application itale(gpdsI Dispersal Area Required(st) Dlspsaml Area Proposed(si) System Elevation <br /> 600 0.4 1500 1500 93.6'&93.9' <br /> VI.Tank Info Capacity in Total y of Manufacturer it <br /> Gallons Gallons Units 'o _ <br /> u <br /> New Tanks Existing Tanks 'E' c L 4 $i , a F. <br /> a U to � h cc tJ o. <br /> Sgeteo 3kidi T ik 1250 'r 1250 1 Crest x <br /> Dosing«` 750 .--- 750 _ 1 , . Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume• ptomibiItty for hrsInflatian afthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S.` MPIMPRS Ntnrtber Business Phone Number <br /> tot eJt H- . u 1a5j 7/72— 6,02 f71--ee9o3 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1(1 yo eat Oral,vl t I�t jA r, Lc.'i r frij <br /> �VI County/Department Only / _ <br /> A;mrvved 0 Disapproved Permit F/ee/ �c�� ���� "� <br /> Oy A ❑Owner Given Reason for Denial V3! i A6(4"------- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to easaptete plans for the mien and submit fa the Candy ogle nu loler oat less lion 8 Ur s I I Inefiw Is size <br /> SBD-6396(R.11/11) <br />