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-15,4:441017,‘ County V <br /> /e.1:lli.-0 Safety and Buildings Division Dane <br /> i`'p ;' ?,.,,�' 201 W.Washington Ave.,P.O.Box 7162 Soldiery Permit Number(to be filled in by Co. <br /> .a s._;_." I 1 Madison,WI 53707-7162 <br /> `' <;_.::s, -,; O 1 (,)—CX 2€ <br /> „,1 ,,,,j <br /> Sanitary Permit Application StateTmnsaclhurtNumber <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate govetntnentai unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to ' Project Address(if different titan 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.13.04(11(m),Slats. Hwy 138 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel g <br /> Hamacher Lawn Care LLC (Open Field Properties LLC) 0510-121-8650-0 <br /> Property Owner's Mailing Address Property Locution <br /> P.O. Box 302 coat.La <br /> City,State ZIpCode Phone Number NW 'ac. NE yo, Section 12 <br /> Stoughton,WI 53589 T 5 N; R 10 {cnc)EoraW <br /> II.Type of Building(cheek nil that a v Lot q <br /> ❑t or 2 Family Dwelling-N ••1•,•. 2 Subdivision Name <br /> w <br /> D Block n . <br /> ®Public/Commercial-0 11 1'' ..7.41 ❑City of • <br /> CSM Number ❑Village of <br /> 0 State Owned-Describe Use MAY 18 2016 Rutland <br /> 14189 ®Town or <br /> III.Type of Permit: (Check only one trublbullleellt l i npl t tine B Handleable) <br /> A. �r�� ph�1re>-t�i Hea�t�l <br /> New System ❑R c p l a C e M e r�S y s em W i n k li n g nkfingThnkReplacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous PetmitNumba and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑AI-Grade ❑Mound->24 in.of suitobte soil ❑Mound<24In.ofsuitablesoil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> \rrDispersaUl'kentment Area Information: <br /> 'Design Flow(gpd) Design Soil Application Rale(gpdsl) Dispersal Area Required(s4 Dispersal Area Proposed(st) System Elevation <br /> ( 96 x70.4 40 378 100.5 <br /> VI.Tank,-Info Capacity in Total H of Manufacturer y = <br /> -..`' Gallons Gallons Units _ g <br /> U <br /> New Tanks EcisdiF Tanks ea c 3 b� ;g d .2 <br /> 4.*U rA .n c_0 a+ <br /> Septic or Holding Tank 700 700 1 Crest x , <br /> DosingChnaibcr 550 550 1 Crest _ x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pt ber's Name(P' t) Plumber's S ... re MP/MPRS Number Business Phone Number <br /> 214, ieI 4c.p f if _£f' 0S. <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /q 7 r/ <br /> VIII.County/Department se Onl <br /> Pe it Fee Date 1 I _Agent _ „ . <br /> Approved ❑Disapproved S r., <br /> ❑Owner Given Ronson for Denial ( 3V 1 ' _ '7i?'c . ,. -- -= °` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> fr J7 1 <br /> Attach In complete plans for the system and submit to the County only on paper not less than A 12 s I1 Inches Insist <br /> SBD-6398(It. 11/1 1) <br />