Laserfiche WebLink
0 . <br /> �.g ., County TAM <br /> l <br /> fit:i-•:,,: • Safety and Buildings Division Dane <br /> ft'U Sy;?!4 201 W.Washington Ave.,P.O.Box 7162 soldiery Pamir Number on be Sited in by cm) <br /> i Pst Madison,Wi 53707-7162 <br /> 1 - Zol6 00(8-4- <br /> Sanitary Permit Application State TummctimNunber <br /> to accordance with SPS 36321(2).Wis.Aden.Code,submission OMB Soto to the apropaiale governmental unit <br /> is.ngatsed prior to obtaining a sentay penult.Noe:Application forms for slate-owned POWTS we submlucd to Project Address(ifdiferent than mailing address) <br /> We Department of Safety and Professional Ser vies. Personal information you provide stay be used far secondary <br /> plepoms io nem:dance with the Privacy Law,s.(5.04(1)(m).Slats. <br /> L Application Information-Please Print All lnfoftnaMe{E C E I V E D <br /> Property Owner's Nome K Parcel 9 <br /> Tatyana Budker 0808311-2320-1 <br /> Property Owner's Mailing Address JUN 2 7 Mb Property Location <br /> 5141 Sunrise Ridge Trail _ Govt.Lot <br /> City,Sala � <br /> n,bre , NW . NE u,section 31 <br /> Middleton,WI 3 2nvirormenta Reaith (crcleone) <br /> II.Type of Building(check all that apply) Lot g T 8 N. R 8 E or W <br /> i <br /> a I or 2 family Dwelling-Number of Bedrooms 3 30 Subdivision Nome <br /> ❑I'ublk/Comnerciel-Describe use <br /> RE C E IV i `C Sunrise Ridge Estates-1st Addition <br /> ❑sty of <br /> ❑slate owned-Describe Use JUN:3 7 2016 CSM Number ❑Village of <br /> al Town of Springfield <br /> Ili.Type of Penult: (Check only one box toPplehialiC ti.t <br /> , I H2ta 0rt <br /> if applicable) <br /> A' ❑New system 8 Repacemen Wtor i eta reuAfoldmgToak <br /> Replacanem Only ❑Other Modlrruxrton W Existing System(explain) <br /> B. ❑Permit Katmai 13 Permit Revision ❑Change of Plumber ❑Permit Transfer to New usf Previous Numb Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device:(Check all that apply) <br /> M Non-Pressurized In-Ground ❑Pressurized In-Ground ❑AI-Grade CI Mooxl>>24 or.of suitable soil ❑Mound<24 in of suitable soil <br /> ❑(holding Took ❑Other Dispersal Component(=plain) ❑Pretreatment Device(explain) <br /> V.DispersaUrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdkQ Dispersal Area Required(s0 Dispersal Area Proposed(s) System Elevolion <br /> 450 0.4 1125 1200 Equiv. 98.0',97.5',96.6' <br /> Vf.Tank faro Cspoe(ty in Total Cot Manufacturer <br /> Gallons Gallons Units 1 I u$ .g <br /> New Treks Ethane Teaks m rn d.O 8 a <br /> `U : a <br /> slain'41'7°4Taek 1000 1000 1 Crest x <br /> Doslee Cbearber 600 "—' 600 1 Crest x <br /> VII.Responsibility Statement-I,the andersigaed,canna responsibility for Installation of the POWTS shown on the oltacked plans. <br /> Plumber's Name(Print) / P MP/MPRS Number Business Phone Number <br /> R Lt o«t k ?.S.(:, I s 9 6.,0e .f'22 d'l`or' <br /> Plumber's Address(Street,City,State.Zip Code) / <br /> Pi qo oak t' �.t� v4 _(/z,,; t U._r___ T-2,r- - - <br /> VUi.County/Department Only <br /> ✓ ter J ����___ <br /> %Approved ❑Disapproved Penal Pus c Issued Issui /' `�;/r,''�v `�--� <br /> S 5) J '�Q-241(C �� `1 1FFf <br /> ❑Ourrner Given Reason For Denial _e <br /> IX Conditions of Approve easoos for Disapproval �FLa� 1 f <br /> D�tj a�,nr�r mid C3� 3 � <br /> MD C9 3(,c 3°'c.EGG,f. 6..t.5 4.e = /2.4:, f.- -__....._ _ <br /> —T OA() J ?2i(- �NYK ' DMI r Fz To °E '4'' <br /> Allah to teoplNe pleas for the epteo sad=bolt to the Canty only no paper not less than II tar I I Inches le else <br /> SBD-6398(R.l in I) <br />