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SCANNbv <br /> ii;f ,*�; Safety and Buildings Division County Dane R g <br /> :s QS '!' =rl 201 W.Waghington Ave.,P.Q.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P.:' Madl on,WI 53707-7162 <br /> VII <br /> ,y j /3 _-2o/G — dCI9/ <br /> y <br /> Sanitary Permit Application State Tmnsmo ion Number <br /> to accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forks to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Nate Application forms*gate-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Profcsslonat Sereies. Personal infamuttton you provide may be used for secondary <br /> purposes in accordance with the privacy Law.E.11040 MI Rad.Slats- F c F T /r r1 CTH V V <br /> L Application Information—Please Print MI Informati (`s 11 \lf1 }ice lrJ1 <br /> Property Owner's Name Farrel d <br /> Wesley Statz AUG 12 2016 0811-142-8530-0 <br /> Property Owner's Mailing Address Property Location <br /> 5707 CTH V V Public Health MDC Govt Lot <br /> City,State ZIP .,e alVIIeyr tga Hteallh <br /> NW '4, NW!G. Section 14 <br /> Marshall,WI ;559 one) <br /> T 8 N; R I I (circle or N <br /> II.Type EorW <br /> ape of Building(check all that apply) Lot g <br /> 0 I or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block I( 31.33 Acre Metes&Bounds Parcel <br /> D Pubiic/Comnxreiai—Describe use <br /> 0 City of <br /> 0 Slate Owned—Describe Use CSM Number 0 Village of <br /> 0 Town of Sun Prairie <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A' ®New System 0 lacement System}gran ❑Trtatmenrllibkling Tank Replacement Only 0 Other Modification to Existing System(=plain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Pijnnber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade', 0 Mound>>24 is of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s) Dispersal Area Proposed ist) System Elevation <br /> 750 0.6 1 1250 _ 1250 91.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> c <br /> New Tanks Existing Tmdts 'el g 3 g °-j' , i3 <br /> it t.) rii . m iZ O o. <br /> Septic ert,e"as Tank 1000/650 — <br /> 1650 1 Meade x <br /> ambit Chmuber 650 —" $50 1 Meade x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the PoWfS shown on the attached plans. <br /> P ''s Name(Print) P 's Signature MP/MPILS Number Business Phone Number <br /> l7Ur �A. �tv�� L� .2 23 t 5 (�QS-83 i -al a3 <br /> Plumber's�ress(Street,City,State.Zip Code) <br /> (c 4 Cou,J }41C1b{ ■ A•f K , kki.A-ufr J A t4..e. . \All 53597 <br /> VIII.County/Department Use Only <br /> ►pprcved 0 Disapproved Permit Fee QDate Issued Issuing Agent ' Aile-hd--/— ,, -'- 0 Owmx Given Reason for Dermal (x v--t J"„ZQt , <br /> I.X.Conditions of Approvat/Reasons for Disapproval <br /> € c-7 A -�► � lit-- Q 4' is- d E7' <br /> P 'C o, 6��. ,Ca e... aN� -Ii r rote. C -c4- ,;/r��; <br /> rl <br /> CCAL11-4 He c <br /> Minch to complete phms for the system and submit to the County only on paper eat less than A la s II larks la size <br /> SBD-6398(R.I1/1 I) <br />