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<br /> A _ _�,,,,,90� Safety and Buildings Division County
<br /> 201 W. Washington Ave.,P.O. Box 7162 Dane
<br /> Aif i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.)
<br /> Department of Commerce 51 7S,9 s s-km Z
<br /> Sanitary Permit Application 138 997 action Number r
<br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental
<br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address)
<br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Flyhawk Lane
<br /> purposes in accordance with the Privacy Law,s. 15.04(IXm),Stats.
<br /> I. Application Information-Please Print All Information
<br /> Property Owner's Name Parcel#090718487200,
<br /> Daniel Heffron,Heffron Co.Inc. 090718383401 &090718490705
<br /> Property Owner's Mailing Address Property Location
<br /> 2000 Prairie St., Ste 220
<br /> Govt.Lot
<br /> City,State Zip Code Phone Number SW v.,SE'Y., Section 18
<br /> Prairie du Sac, Wi. 53578 (608)643-8525 &SE 1/4, SW 1/4 Sec 18
<br /> II.Type of Building(check all that apply) • Lot# (circle one)
<br /> n 1 or 2 Family Dwelling-Number of Bedrooms T 9 N; R7 E• . 1, 2,33,34,3538,39, Subdivision Name
<br /> ® m
<br /> illy ,1 Black Hawk Fields
<br /> Public/Commercial-Describe Use JJ
<br /> System No.2
<br /> Community system-12 lots,40 bedrooms n/a n City of
<br /> CSM Number n Village of
<br /> n State Owned-Describe Use
<br /> n/a ® Town of Roxbury
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A. ® New System n Replacement n Treatment/Holding Tank Replacement Only n Other Modification to Existing System(explain)
<br /> System
<br /> B. n Permit n Permit Revision n Change of n Permit Transfer to List Previous Permit Number and Date Issued
<br /> Renewal Before Plumber New Owner
<br /> Expiration
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ® Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
<br /> ❑ Holding Tank ❑Other Dispersal Component(explain) N Pretreatment Device(explain)BioMicrobics FAST(2)3.0's in 5000 gallon tank
<br /> V.Dispersal/Treatment Area Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
<br /> 6000 1.60 3750 4800 821.80
<br /> VI.Tank Info Capacity in Total #of Manufacturer w o
<br /> Gallons Gallons Units u u
<br /> New Tanks Existing Tanks ti o F H F 0, a .<i
<br /> a u N rn rn iZ D P.
<br /> Septic or Holding Tank 10200 10200 2 Wieser IA n ❑ ❑ ❑
<br /> -Dosing Chamber 5000 5000 1 Wieser M O D E I D
<br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) lu ber'raItu're MP/MPRS Number Business Phone Number
<br /> Mark McNeely Y��t� !I 224724 (608)643-12881
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 850 19th St. Prairie du Sac,Wi. 53578
<br /> VIII.County/Department Use Only
<br /> /(Approved _ Disapproved Permit Fee Date/Issue Issuing Agent Si atu ,'_Owner Given Reason for Denial $ ' i . — 11/21)0 7
<br /> tPl p ANTI G )Fiji,APPROVAL. DANE C^;t°'�_/
<br /> IX.Conditions of Approval/Reasons for Disar�� r,'n-n,TA, 'r1_.7+ 3Y
<br /> LIP 71 FOcf ANY CE, r. r n FE t'` I W '
<br /> Ti,„,,, r'l �n �; � L it �tF4J OR '>1 � �r i�.A- � 1
<br /> A i'�'. )N ApAIN! l t-, r
<br /> -r Try h r: I {:/ Vp f",f;^s
<br /> ft !i r.)' AFTER f +S1A ;(1U
<br /> Attach to complete plans a the iysiin4aM)sdbi;tr rtpi hrcouoty only pnpaper ntit,Sf'theil�$Y/2 x I c In sizeN(jv 2 0 2007
<br /> NECESSARY.
<br /> SBD-6398(R.01/07)Valid thru 01/09 Dane Cou t/rmr ra mental
<br /> W, l' ^eat
<br />
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