Laserfiche WebLink
ieViTke►i County <br /> tee', ;:;;•" Safety and Buildings Division Dane e I <br /> :I'�" 201 W.Washington Ave. P.O.Box 7162 <br /> '�'�' �;, � ng Sanitary Permit Number(to be tilled in by Co.) <br /> -4(1::;1!:','W$ '' t Madison,WI 53707-7162 <br /> V.`^--•1 <br /> Sanitary Permit Application State TnmsactionNumber <br /> In acconlance with SPS 383/1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pennit. Now Application roans for state-owned POINTS 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 Xr),Slats. Eldon Way <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Rob Hostrawser 0512-054-5721-0 <br /> Property Owner's Mailing Address Property Location <br /> 1174 Nira Lane Govt.1.01 <br /> City,State Zip Code Phone Number SW i„, SE y,, Section 5 <br /> Edgerton,WI 53534 213-1807 (circle one) <br /> T 5 N; R 12 EorW <br /> Ii.Type of Building(cheek ail that apply) Lot# <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 --- 21 Subdivision Name <br /> Block# Blue Meadow Estates <br /> 0 Public/commercial-Describe Use <br /> 0 City of • <br /> 0 State Owned-Describe Use CSM Number ❑Village or <br /> ®Town of Albion <br /> ill.Type of Permit: (Check only one box on lime A. Complete line B If applicable) <br /> `I et New System 0 Replacement`System 0 Treatment/holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) <br /> ®Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound?24 in.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 lnfarmntlon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(so Dispersal Area Proposed(si) System Elevation <br /> 450 0.4 1125 1128 93.0, 93.5,94.0, 94.5' <br /> VI.Tank Info Capacity in Total #or Manufacturer <br /> Gallons Gallons Units o _o OS New Tanks Existing Tanks 0 a g .a a <br /> 0.tot 'v5 ,., s E tJ a. <br /> Septic°MeldingTtntk 1000 1000 1 Crest x <br /> Dosing Chamber 600 -� 600 1 Crest <br /> x <br /> Vii.Responsibility Statement-I,the undersigned,ersumc} ..nsibltlty for installation of the POWTS shown on the attached plans. <br /> PI s Name(P' Plumber's f„' MPIMPRS Number Business Phone Number <br /> -1 tiZ L-- �� -7(7.4. tr•eS2 g?3 -J-", 'o? <br /> Plumber's Address(Street,Chi,State,Zip Code) <br /> r '2i'" c al- tip 4.., or -.- 14, t,•.a- s-701 <br /> `'1 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved <br /> Permit Fee Date Issued?� Issui nt <br /> D Owner Given Reason for Denial S q+l1. t q J—.2ot•6 C.ions of Approval/Reasons for Disapproval ."-----•• C E I V E D <br /> SEP 14 2016 <br /> Public Health MDC <br /> Attach In complete plans for the system and submit to the County only nu paper not less than ti IC a II inches In stztnvironmental Health <br /> SBD-6398(R.11/11) <br />