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irt+R+ig'y� County <br /> 1. t r;,,•. Safety and Buildings Division Dane J <br /> • t '.$ �` 201 W.Washington Ave,P.O.Box 7162 Saniary Permit Number(lobe filled in by Co.) <br /> P 1=( Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> to accordance with SPS 3833112),Wis..Arlin Code submission of this toms to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note Application fonts for state-owned POWTS are submitted to Project Address(if differed than mailing address) <br /> der Department of Safety and Professional Scrvlcs.Personaltafontutlonyou provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.IS04(1)(m)Slats. Kollath Rad <br /> t.Application Information—Please Print All Information <br /> Property Owner's Name Parcel x <br /> Art's Custom Design Builder LLC(Art Hill) 0607-264-9230-0 <br /> Property Owner's Mailing Address Properly Locution <br /> 1969 N.Kollath Road Govt.Lot <br /> City,Sate Zip •• • Number SW a, SE 'A,Section 26 <br /> Verona,WI / 5359 T 6 N: R 7 (a e o ear <br /> Ii.Type of Building(check al apply) Lot <br /> ®1 or2 Family Dwelling-N •-of Bed• 4 2 Subdivision Nome <br /> • ..(" r • Blocks <br /> ❑Pubge/Commereiel- <br /> ❑City of • <br /> ❑State Owned-Describe Use JUL 0 : 2016 CSMNumber ❑Village of <br /> Public Health MDC 10305 <br /> M Town or Springdale <br /> Ill.Type of Permit: (CrrI1vippr*i*4ap illisallticomplete line B if applicable) <br /> A. ®New System ❑Replacement System ❑Treatment/Roldog Tank Replacerncm Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Rcrisida <br /> ❑Change or Plumber ❑Permit Transfer to New List Previous Permit Number and Date issued <br /> Before Eitpiretion Owner <br /> IV.Type of POWTS System/Component/Device: (Check aB that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurised la-Ground ❑Al-Grade DI Mound'24 in•of suitable soil ❑Mound<24)0.of suitable soil <br /> ❑Holding Tank ❑Other Disperse)Component(explain) ❑Pretreatment Device(explain) <br /> V.Dlspersal/Treatment Area Information: <br /> Design Flow(pd) Design Soil Application Rate(gpds0 <br /> Dispesal S6a 6 hrd(s) Dispersal Area {sQ` System Elewlia <br /> 600 ?. � 1, , k6' (° <br /> 103.5' <br /> VI.Tank Info Capnehy in Total it of Manufacturer • <br /> Gutless Gallons halls G o$ u <br /> New Tanks Esistns Tanks a S 1 ' 21 B <br /> r u q Pi lZ O i <br /> Septic ornnwunsrtwk 1250 1250 1 Crest x <br /> DODO o°"'b" 750 750 1 Crest <br /> x <br /> VII.Responsibility Statement-1,the andersigaed,assume responsibility for Installed=of the POWTS shown on the aitecked plans. <br /> Plumber's Nome(Print) Phm Signatures MP/MPRS Number Business Marne Number <br /> **j cr.,IS ag vti t _` �--- ,'"�" )c D 8Z- 41-301'x/ <br /> Plumber's Address(Street,City,State Zip Code) <br /> .1)-7g(99 d r j i? ..sn j c3(5343 -: )•° <br /> VII).County/Department Use Only \/�... <br /> J Permit Fee Date !sal Assent S' .,yam 1.0 Approved ❑Disapproved _ <br /> ❑Owner Given Reason foe Denial �y -,end 6 /..` �� <br /> IX.Conditions of Approval/Reasons for Disapproval �.�+"�� - <br /> i <br /> Minch le complete plans f o r the aster,and submit Is the County only on paper not less than a to I I I Inches In size <br /> SBD-6398(R.I I/11) <br />