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^+ ,ay■�f�}+a per: <br /> , $ SCAN77En <br /> County <br /> Safety and Buildings Division Dane <br /> 3r zU,y_. � 201 W.Washington Ave,P.D.Box 7162 Smithey Permit Number po be filled in by Co.) <br /> U.P Madison,WI 53707-7162 <br /> - o1b-0013 <br /> Sanitary Permit A �� Stoic Tram:mina Number <br /> to accordance with SPS 38321(3),Wis.Adm.Code,submission In Ih ImI unit <br /> is required prior to obininiog a sanitary pesroiL Main Application 0 hied to Project Address(if different than mailing address) <br /> the Department of Safety and Profcssionol Scenes.Personal inforvmrton you provide may be used for secondary <br /> purposes in accordance Milt the Privacy Law,s.(5.04(I)(m).Slots. JUN-3 2016 Britt Valley Road <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Public Health MIX Parcel <br /> Robert&Gaye Fredrick Environmental Health 0507-081-9550-6 <br /> Property Owner's Mailing Address Property Locate <br /> 2618 Highway 92 <br /> Govt.Lot <br /> City,Slate <br /> rat Caere Phone Number SE iS, NE 14,section 8 <br /> Mt.Horeb,WI 53572 (cirvkone) <br /> 11.Type of Building(cheek all that apply) Lot g T 5 N; R 7 E a W <br /> Ei I or 2 Family Dwelling-Number of Bedrooms 3 Subdsvmm Name <br /> Block# 15.4 Acre Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe use <br /> CS Number ❑Vllhuge of <br /> ®Tasen of Primrose <br /> Ill.Type of Permit (Check only one box on line A.Complete line B if applicable) <br /> New System ❑Re t <br /> plucemen System ❑TreatmmVHoldrsrg Tank Replacement Only ❑Other 1vladGxation to Existing System(explain) <br /> B. ❑Permit Rencoel ❑Permit Revision List Previous Permit Number and Date issued <br /> ❑Change ofPlurrdrer ❑Permit Trmsfc to Nnv <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized la-Ground 13 At-Grade ❑M000d>24 in.ofsudoble soil ❑Mound<24 in.of suitable soil <br /> ❑tloidingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/TreatmentArea Information: <br /> Design Flow(epd) Design Soil Application Rne(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(s0 System Elevation <br /> 450 0.6 750 750 94.3' <br /> VI.Tank Info Capacity.in Total 9of Manufacturer <br /> Oettons Gallons Units ere u 8 ra <br /> New Tanks Existing Tents a <br /> td s 3 .$a a <br /> Tmlr 700/550 1250 1 Crest x <br /> Dazing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the PO WTS shown an the Winched plans. <br /> Plumber's Nome(Print) Plumber' lure NIP/MPIIS Number Business Phone Number <br /> --MoLS O€ set- /cazzs2 yZY3061 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /ti78b? erre 6' elle�rl� <br /> VIII.Corn /De nrtmenl Use Only <br /> PProvcd ❑Disapproved Permit Fee a -rya , <br /> ❑Owner Given Reason for Denial <br /> 5 !/ t4ir��l <br /> IX-Conditions of Approval/Reasons for Disnpprovnl <br /> Attach to complete plans for the system and submit to the Comely only on paper not Ins than 8 to s I I inches In she <br /> SBD-6398(R.I I/11) <br />