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SCANNED $§`n^°.;� County ' > ;;.;,,, `*;s Safety and Buildings Division Dane J(� ,g1 s , ; 201 W.Washington Ave.,P.O.Box 7162 Sungari Permit Number(to be filled in by Co.) .1 P ' r Madison,WI 53707-7162 • Sanitary Permit Application Stom Transaction Number • In acrordunce with SPS 383.21(2).Wis.Adm.Code submission of this form to the appropriate govennnennl unit is required prior to obtaining a sanitary permit.Note Application fauns for stalo-owned FONTS-are submitted to Project Address(if different than mailing address) the Dcparanenl orsafety and Professional Berries Personal Inrorrnatba you provide be used r e nary perpns.in accordance with the Malley Lan,s.15.04i1)(m).Slats.. ('� C C IV U 1185 Highway 14 I.Application lafurntellan Plense Print AU information K C V Property Owner's Name ' Parcel 0 Bucky's Portable Toilets,Inc. JUL 2 0 2016 0510-073-8000-6 Property Onneri Mailing Address Property Location 1282 County Highway MM Public Health MDC cart.La City,State Envi rjgra i Health NE s, SW r,sedan 7 Oregon,WI 535 5 835-3459 (circle orte) IL Type or Building(cheek aB et apply) 8 T 5 N; R 10 Eor1V ❑I or 2 Family Dwelling-Nwober of Bedrooms subdivision Name Block4 33.7 Acre Metes&Bounds Parcel ®rubiic/Cormmecial-Descrike Use Office/VVarehouse • L ❑Cily or ❑State Owned-Describe U!C CSh'i Nmnbc ❑Village o! `.� i,Town err Rutland III.Type of Permit: (Check only one box on line A.Complete line B If applicable) 't• ❑New System ❑Replacement System ❑Treattnmrhloking Tank Replacement Only ®Other Modification to Edsliag System(espluin) Reconnect to existing system B. ❑Pamir Renewal ❑Permit Revision ❑Change of Plumber ❑Panal Transfer to New List rm.iasst/rams Number and Dute Issued / Before Expiation Owner 411 I :,$ y-(8 2.0 IV.Type of POWTS System/Component/Device: (Cleckall that apply) rArldt-2V Z, ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 0 Mound 8 24 in.or suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Disposal Component(explain.) ❑Pretreatment Device(captain) V.Dispersal/TreatnentArea lnfarnintlon: Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(sr) Dispersal Area Proposed(s)) System Elevation 576 0.7 823 2856 Existing(0.2 _oad) VI.Tank Info Capacity in Total 4 or Manufaaeter Gallons Gallons Units - o' v u� New Tanks Earning Tanks c y X ad '-E r..v Fs vet EU a sep te.c4 gTn.t 3000+1250 4250 2 _ Crest&Dalmaray x Dosing Chamber 2000 2000 1 Dalmaray x VII.Responsibility Statement-1,the undersigned,assume responsibility for Insttdlallua of the FOWLS shorn on the snitched pions. Plumber's Name(Print) Plumber's Sigarsolae MPIMPRS Number Business Prone Number .� •P u 1 I L4 ` -) f ,'"t. �3 34)l t;�t�`'�s• 1-11-1 t.r-C4 -.�. Plumber's Address(Street,City,State.Zip Code) ......W.._�.�.W.w. t (3 _ 4 -__-...- VIII.County/Department Use Only ,t Appmacd ❑Disapproved Pemtit Fee Dam issued Issuing Age Si ��%C�Y�U S �y-� n ❑Owner Giren Reason for Denial f-' I l !-22 bJ IX.Conditions of ApprovnlfRensons for Disnpprovnl Re-ter,'-.r(tr&- -6.'m s'r a"atGin1in>/ rcrr cD a .• 574 F Dfi1L wAllc--tv 1'4D op 1'e3 M-1 /. x. M Arad.to complete pions for Ilse.ryntem and submit to the County only no paper nut less limn A Ill r I I lathes In slat SBD•6391(It.I Ill I) • •