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i.•eu+ia� County <br /> t':1'� Safety and Buildings Division Dane <br /> s. .1:4'6-.1.''?` Vi 201 W.Washington Ave.,P.O.Box 7162 San(ary Permit Number(to be filled to by Co.) <br /> y; Madison,WI 53707 7162 <br /> ,= � � 13 °tic-� OO( <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission oftb•11. . al: .e it <br /> is required prior to obtaining a sanitary permit. Note:Application ro ,• ,•. .v''^^ u•" • - <br /> 17ir"� to Project Address(if dirfer nt than mailingaddmss) <br /> the Department of Safety and Professional Servies. Personal infannat(on you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. JUN - 2X016 7079 Frenchtown Road <br /> I. Application Information-Please Print All Information <br /> Property Owners Name Parcel 0 <br /> Joe Disalvo Public Health MDC 0508-223-8820-0 <br /> Environmental-klealth <br /> Property Owner's Mailing Address Property Locution <br /> 1407 Range Trail Govt.Lot <br /> City,Stale Zip Code Phone Number _ --,-K , SW w, section 22 <br /> Verona,WI I 53593 v / 'A (circle one) <br /> II.Type of Building(check all tha ■ y) Lot ,/ T 5 N; R 8 E or W El I or 2 Family Dwelling-Number. Be'rooms 3 I f/ 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ❑Slate Owned-Describe Use CSM Number ❑Village of <br /> /14240 Cil Town or Montrose <br /> Iii.Type of Permit: (Check only one box on line A. omplete line B If applicable) <br /> A' 21 New S y stem ❑Replacement System ❑Treatment/Holding Tank Replacement rnt only ❑Other Modification to Editing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and We Issued <br /> + <br /> Before Expiration Owner <br /> IV.Type of POWFS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ®At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Aren informntion: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) I D)spexsaj,Area Required(s[) Dispersal Area Proposed(so System Elevation <br /> i"450 t.-' 0.6 ✓ 750 1 ,.--"750 I 97.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ru o Tl ci <br /> New Tanks F.:tains Tanks u <br /> c t..) in. en E O a. <br /> Septic or Holding Tnnk 1000 1000 1 Crest x <br /> Doing Chaadxr 600 600 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POW TS shown on the attached plans. <br /> Plumber's Name(Print) Phtm Signature MvMP/MPRS Number : -•-- u,•, Number <br /> 7. " 5 C � 0/0 - 4/7.1(-.30 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /V 7g041 CE-9 Of7 r��f fie L 1 oA y <br /> VIII.County/Department Use Only i <br /> Approved ❑Disapproved Permit Fee Doto Issue Age -• <br /> ❑Owner Given Reason for Denial S 6, A j <br /> IX.Conditions of Approval/Reasons for Dlsnpprova� rr <br /> Attach to complete plans for the system and sabmit to the County only on paper not less than 8 Itz s I I inebas In size <br /> SBD-6398(R.11/I l) <br />