Laserfiche WebLink
. I DI,t.,Lp IE fl v I -iv, <br /> I i•i FEB 25 II <br /> . <br /> . commerce.wl.gov Safety and Butldinga Divisi l• County Dane <br /> a tin t;W ; .h(pg B ?tb <br /> r .Al S 62 � Sanitary Permit Ntmeber to tilted in by Co.) <br /> Sanitary Permit Application State Transaction Number <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 tbennniiingaddress) <br /> submitted to the Department of Commerce.•Personal information you provide may be used for secondary <br /> purposes In accordance with thsPrlvaey Law,a.15.040)(m),State. 4017 Highway 73 <br /> I. Application information-Please Print AU Information - <br /> Property Owner's Name Past a <br /> Gary&Sheila Borgrud 0712-164-9560-9 <br /> Property Owner's Mailing Address Property Location <br /> 832 Zander Road Govt Lpt <br /> 'City,State Zip Code Phone Number SE 'h, SE lt,section 16 <br /> Deerfield,WI 53531 „T 7 N; R 12(circle o�w <br /> ' H.Type of Building(check all that apply) Lot N - <br /> fl 1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 'SubdivisionNante <br /> Blocks 1.5 Acre Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use 0 City of <br /> GSM Number 0 Village of <br /> 0 State Owned-Describe Use " <br /> Deerfield <br /> n Town of <br /> III. ! +y.f Permlk ( . 4 ,nlrongox on Complete line B if applicable) <br /> A '-. -'!,s;:. a Replacement System TreatmentlHoldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision CI Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Data issued <br /> Before Expiration Owner , <br /> P/.Type of POWIS SyatemlComponent/Deviees (Check all that apply) <br /> )(Non-Pressurized In-Ground 0 Pressurized in.Oround 0 At-Grade 0 Mound>24 in.ofaultable soil 0 Mound.c24 in of suitable soil <br /> !!O Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DlsperaaVTreatmetIt Area Intoriaatlont <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(11) Disperse.Area Proposed(si) System levation <br /> 450 0.4 I 1125 I IV1128 fri4.0. <br /> VI.Tank Info Capacity in Total Nor Manufacturer <br /> Gallons Gallons Units <br /> •New Tote Ueda Tanks <br /> Setta.o oldhssTeak 1286 1286 1 Meade(819/467) x <br /> DoeiasCl ember <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for idstal/J ,I iation oftfthe POWIS shown on.the attached plans. <br /> lumber's Name ) Plumbs Signatur PO Phone <br /> Number <br /> 1 l.t' l WU 0. v p t <br /> q <br /> umber' A ress( heet,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee pa/d Date Issued �-,issruuin `gent Signatu i _ / <br /> �/�` ❑Owner Given Reason for Denial s L . �3 ' (Y-mill!— T' rIIIV <br /> IX.Conditions of ApprovaUReasoni for Disapproval cos , h_ <br /> Attach to sample.platy for the systems pad.ebn di to the County only ea paper not leas than It in x 11 Inches fa she <br /> IN GRANTING THIS APPROVAL, DANE COUNTY <br /> SBD-6398(R 01/07)Valid ihfu Ol/o9 ENVIRONMENTAL HEALTH DOES NOT HOLD r SELF <br /> 1 LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFICA <br /> TIONS, PLAN OMISSIONS,EXAMINATION OVER- <br /> Ch/IC(� , r"id t �•-) SIGHT,CONSTRUCTION OR ANY DAMAGE THAT MA\ <br /> �J/V�( (� (�f' RESULT IN OR AFTER INSTALLATION AND RESERVE <br /> THE RIGHT TO ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING i THIS <br /> NECESSARY. <br />