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�/ County Dane <br /> SCANNED <br /> :�=^ .,,,. R E C E I <br /> • ,;; Industry Services Division e/r) <br /> 4., B - 1400 E Washington Ave <br /> i•s Sp ill JUL 2 8 2016 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> is $X ;r <br /> • Madison,WI 53707-7162 <br /> �..- ' Public Health MDC <br /> Environmental Health <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. 7914 Bowman Rd <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel II <br /> Larry Grab 050/0907-011-8051-8 <br /> Property Owner's Mailing Address Property Location <br /> 1501 Brynwood Drive <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE 1/2, NE 'h, Section 1 <br /> II.Type of gson, Wat .IPPIY) 53716 Lot 608-217-2428 T 9 N; R 7 (circa one) <br /> et X I or 2 Family Dwelling Number of Bedrooms 4 1 Subdivision Name <br /> Block 8 <br /> ❑Public/Commercial—Describe Use _ <br /> ❑City of <br /> ❑State Owned Describe Use CSM Number ❑Village of <br /> 8524 X Town of Roxbury <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) T <br /> A. <br /> X New System ❑Replacement System ❑Treatment/I ioldmg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 1=1 Permit Renewal CI Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) J <br /> X Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade El Mound>24 in of suitable soil ❑Mound<24 in of suitable soil <br /> ❑1 folding lank X Other Dispersal Component(explain)EZ Flow 1203 H El Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sO Dispersal Area Proposed(so System Elevation <br /> 600 0.4 1500 1500 C-1 96.0/C-2 94.9/C-3 93.7 <br /> VI.Tank Info Capacity in Total !t of Manufacturer <br /> Gallons Gallons Units il o 73 y <br /> New Tanks Existing Tanks w e U — <br /> C 1. N <br /> -. d in y e,-5 W C7 0. <br /> Septic or thtletn g-a.d: 750/ 500 1250 1 Crest x <br /> Dosing Chamber 750 -- 750 1 Crest x <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb is Signature _} ThW/MPRS Number Business Phone Number <br /> Kenneth Haugen Plumb <br /> "C? 224121 608-205-0238 <br /> Plumber's Address(Street,City,State,Zip Code)317 W. Broadway Street Stoughton, Wi 53589 <br /> VIII.County/Department Use Only <br /> ❑Approved Cl Disapproved Permit Fee Date Issued Issuing..: nature <br /> ❑Owner Given Reason for Denial $ 7�/ C8/03//G '^C%�`� sLf Ai!/ _ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Oar e 's /�'UT 7n L-`tGeeo /2 6.44,. 'lA,pes r posd <br /> SRoc\ i23 6 TA iZ ) &4L, Ev DtS Pi.4 M&Nr ors SI1jhM Iuf- • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I i inches in size <br /> SBD-6398(R0313) <br />