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SCANNED <br /> / ., _ __ _County <br /> /;f;=:,,__��x Safely and Buildings Division Dane R H <br /> .)' .0$ti: ':pi 201 W.Washkgbn Ave.,P.O.But 7162 S®iugr Permit Number no be Riled in by Co.) <br /> .‘t P; Madison,WI 53707-7162 <br /> _ - 1,-v3.U/L -U0aa3 <br /> Sanitary Permit Application Stale TrmeanimNumber <br /> la accordance wilt SPS 31331(2).Nee.Adm.Coda submission of this them to the emendate gova utattd omit <br /> is requidpd prior to ablating o stitery permit.Note Application forms for stale-owned POWr5 are sobadOed to Project Address(if di(farnt ton mailing address) <br /> the Deportment of Safety and Professional Series. Personal information you provide may be used for someday <br /> omens=in.ccad®ee with the Prime).Law,s 15114(1 gm),Sim 3269 Deerfield Road <br /> L Application Information-Please Print AB Information <br /> Property Owner's Noose Paled a <br /> Greg&Judy Storms 0711-364-8420-0 <br /> Property Owner's Moilog Address Property Location <br /> 3747 Nelson Road Govt.Lot <br /> City,Sate Zip Code Phone Number NE tit, SE i:.section 36 <br /> Deerfield,WI 53531 T 7 N; R 11(�eo c) <br /> II.Type of Budding(cheek all that apply) Lot A <br /> la 1 or 2 Family Dwelling-Number of Redman; 3 1 Suhdlvtsiert Noon <br /> Block A <br /> ❑Pi biacanmariol-De:eiroe use ❑City of • <br /> 13 Stale Owned-Dream Use ( Number ❑Village of <br /> 8488 el Town of Cottage Grove <br /> III.Type of Permit(Check only one box on line A.Complete line B If applicable) <br /> A' ❑New System a Reybeeomt System ❑Trermle.ntokingTook Replac®ea Only ❑ether Modifieuion to Existing System(explain) <br /> 8. ❑Permit Roland ❑Permit Re iaim ❑Change of Murtha ❑Pena Trensferto New List Pievioas Pena!Nttnba.ad Dote Issue <br /> Before Expiration Owns <br /> IV.Type of POWTS System/Component/Deviea(Check ag that apply) <br /> ®Nan-Ptasolud In-Ground ❑Pressurized to-Good ❑At-Caade ❑Mound 20 is of suRdbte soil ❑Mound<24 in.of suitable soil <br /> ❑holding Talc ❑Other Disposal Component(espl.in) ❑Pretreatment Device(explain) <br /> V.Dlspersal(Trc.tmeot Arm Information: <br /> Design Flow(gpd) Design Soil Application Rate gpdsl) Dispersal Ana Requital(sl) Dispersal Area Proposed(si) System Elevation <br /> 450 0.4 1125 1128 94.0,95.0' <br /> VI.Tank Info C.pmily it Tool A of Manufacturer il Gallons Gallons Units er e u Ti <br /> New Tons Fsirtisr Tans u c .I3 2 2 2 <br /> 1 u m., a a o. <br /> S e p t i c o t Talc 700/550 1250 1 Crest x <br /> Dosing Ckmtaar <br /> VII.Responsibility Statement-I.the u ndersipad.•„ �� • I for hgntlatIoa mike i'owrs shown on the attached plaar. <br /> P s Name(Print) ` Phmtber's'` MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,Stale Zip Code) — .. <br /> /tiPD (Ai_ Op-+r.1 y U� S A, t�_z- sr)) <br /> VIII.Coaaty/Dcpartmeot Use Only te <br /> )(Approved ❑> � Per�(mit fee Dale Issued hai. <br /> ❑Owner Given Reason for Denial 5 (C f. C O 744-20/6 i C <br /> IX.Conditions of ApprovallReasons for Disapproval <br /> —÷ sEerk- rsftr�i., 71, ff2 ,X4oGezy A��P 1), <br /> T 14A/L'Dawhr 040 acqx 4,40 4\4(49 44d.-' Ol,'6 <br /> Attaca to coaptete phoebe the:sae au!whatt I.the Ceuoly ask no paper eat ton taaa a ter x I I Welles In she <br /> SBD-6398(R._l t/I I) <br />