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s' B County <br /> /.{:f V' <br /> Safety and Buildings Division Dane 4 <br /> if`II i 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in Co.) °' <br /> ;,,' >,PS,V. Madison,WI 53707-7162 <br /> Sanitary Permit Application Stare Transaction Number <br /> In accordance with SPS 383 1(2),Wis.Adm.Code submission of this form is the appropriate governmental unit <br /> is expired prior to obtaining o sanitary permit.Note Application fors for state-owned POWTS ore submitted to Project Address(if dilTerent than mailing address) <br /> the Department of Safety and Professional Serviea. Personal Information you provide may be used for secondary <br /> purposes in accordance with the Privacy law.s.15.04(11(m).Slats. Dorothy Drive <br /> I.Application Information-Please Print All information <br /> Properly Owner's Nome Parcel it <br /> Scott&Cheryl Wilson 0610-071-8225-0 <br /> Property Owner's Mailing Address Property Locution <br /> 2861 Henshue Road coot.Lot <br /> City,Stale Zip Code Phone Number SE ,s, NE Y.,Section 7 <br /> Madison,WI 53711 575-7790 m n) <br /> T 6 N) R 10(creo <br /> Ii.Type of Building(check all that apply) Lot k <br /> I or 2 Family Dwelling-Number of Bedromn 4 1 Subdivision Name <br /> RE • Block A' <br /> ❑Public/Commercial-Describe uSa <br /> ❑ckyar • <br /> ❑Slater Owned-Describe Use JUN 0 6 2016 CSM Number ❑Village of <br /> Public Health M�D�C��1, 11916 <br /> ®Town or Dunn <br /> Ill.Type of Permit: (Check onifille 6!4(lfeiil'la 1 a.onsprere line B If applicable) <br /> A' 8 New System ❑Replacement Systertt ❑TreatmenVlokSa C Tunic Only ❑Other Mlodifustion to Existing Svstem(a(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumbcr ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device:(Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑lloldingTank ❑Other Dispersal Component(explain) ❑Pretreatrnem Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rote(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(at) System Elevation <br /> 600 0.4 1500 1500 96.0',97.5' <br /> VI.Tank Info Capacity in Total II or Manufacturer , <br /> Gallons Gallons Units n `o 2 <br /> New Tanks Existing Tanks 9 i5 y g _g 9 <br /> ail in or le O w <br /> Septic w-slowing Trak 700/550 1250 1 Crest x , <br /> Dastne Chamber <br /> ViI.Responsibility Statement-I,Lire undersigned,assume responsibility for iastallatlou of the POUTS shown on the attached plans. <br /> Plumber's Nome(Print) Plumber's Signatmc I1�IMPRS Number Business Phone Number <br /> 5obe1,- Ever 3424, /z ie/7 Z-it'Ae24-e9z-1 ,-2b//41-- 6ec57P-O.2f6J <br /> Phrber's Address(Street,City.State.Zip Code) <br /> 5".71- .5 r,- -ii ct'/i-, /131 G'<^e zy i LG .b 35 75' <br /> Vill.County/Department Use Only <br /> V$Approved ❑Disapproved Per i Fee Dale Issued Issui Agent w <br /> �� S <br /> ❑Owner Oven Reason for Denial 5 , ���(?//� �� �, <br /> IX.Conditions of Approvat/Rensons for Disapprove( <br /> /// <br /> Attach In complete plans for the stem oral suhmtl to the County only no paper oat lest than 8 I2 x I l Incites In size <br /> SBD-6398(R.11/11) <br />