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SCANNED <br /> / f. :� County <br /> r LT:,: Safety and Buildings Division Dane N <br /> ,3l= "„ 201 W.Washington Ave,P.O.Box 7162 Sammy Permit Number(to be ailed in by Co.) <br /> s :::84..i:. �1 Madison,WI 53707-7162 <br /> '. ;ra:Sf}v, <br /> /0 -.241'6_0(y.1 a.c <br /> Sanitary Permit Application State Tummies Number <br /> In accordance with SPS 38331(2),Ws.Adm.Osdc,submission of this loon to the appropriate goy rrunerdol unit <br /> is reqnined prim to obtaining a sanitary pernriL Note Application forms for slate-owned POWIS me submitted to Project Address(if different than mailing address) • <br /> the Department of Safety and Profcssbrral Scales. Pascoe'inforomtlon you provide may be used for secondary <br /> proposes in=cork=with the Privacy Law,s.15.04(1)(m).St <br /> 9�E E T <br /> L Application Information-Please Print All lnforran C L I V !:D <br /> Property Ouac's Name '`L J �/ Petrel a <br /> Gary Trulson 0512-191-9500-2 <br /> Property Owner's Mailing AddressJUL i 9 2016 Property Location <br /> 727 Oak Drive Public Health Mnr Goo.Lot <br /> City,stale •• or r�PRti'I 4alth SE x, NE %.section 19 <br /> Edgerton,WI i 3 608-443-9531 -r 5 N; it 12(Q(circle <br /> II.Type of Building(cheek all .tar•Iy) Lot S <br /> ®I or 2 Pointy Dwelling-Num.-of:- .. Subdivision Nome <br /> • Bleck0 . 40.2 Acre Parcel <br /> ❑Pak/Commercial—Describe Use ❑City of <br /> ❑Stine Owned—Dencnbetisc f tfhmnba ❑Ydknge of <br /> ®Town or Albion <br /> It'.Type of Permit(Check only one box on line A.Complete line B If applicable) <br /> A' ❑New System gI Replacement Syston ❑TreonmmAiolcgog Tank Rephcernem Only ❑Other Modificalton to rsistiag System(esplafa) <br /> B. ❑Permit Renewal ❑Permit Revision ❑(bane of Plumber ❑Peron Trmtsfer to New List Previous Permit Nmnber and hate Issued <br /> Before Expiration Owner <br /> IV.Type of POWIS Systet/Component/Desiem(Check all that apply) <br /> ®Non-Pressurised In-Grand ❑Rooariced to-Groh d ❑At-Guide ❑Monad>24 in.of=Ruble will ❑Mound<24 in.of sudabk soil <br /> ❑Holding Tank ❑Odra Dispersal Component(espkm) ❑Pretreatment Device(explain) <br /> V.DlspersaUTreotment Area Information: <br /> Design Flaw(gad) Design Soil Apollonian Ratd>b4 Disperse!Arm Required(s0 Dispersal Arm Proposed(st) System Elevation <br /> 450 0.4 1125 1134 94.0' <br /> VI.Tank Info Capacity in Total #or Manufacturer <br /> Gofloos Gallons Units Is o$ u <br /> New Tanks Esamt Tanks 'o 3 T, a a <br /> c`U ri iii t O o. <br /> sgae it B0Tsek 1000 1000 1 Crest x <br /> Dosing Clamber 600 600 1 Crest x <br /> VIL Rsponssltiity Statement—I,the andaslgaed,assume ansposu(bluty For bnstanalan err the POSITS sham on die Minded plans. <br /> Plumber's Nana:(Print) Plumber's Sr�mt,re xihIMPRS Number Business Phone Number <br /> Rat er j 'ey5oii I 'ol - ,� eri 6//q- 608-5-75- .1-9-0 <br /> Plumber's Address(Street,Qty.Stilt Zip Code) r <br /> s c -;hcd/n e' oil /2/i 53571" <br /> VIII.County/Department Use Onh• <br /> r Permit Pee '....Dffate issmdq� tsui {��Approved ❑Owner Give S 1/2/ 1 2!�'t 6 4e44 <br /> ❑Owen Given Reason for Denial `7 <br /> I.4.Conditions of Approval/Reasons for Disapproval <br /> Attack to eamplene plans for arc eaten mad submit to Me Canty only on peps rot let thus 1 IC s 11 beges le sbe <br /> SBD-6398(R.l 1/1 I) <br />