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County e
<br /> 4-ill'Ar,,,.. NTeN Safety and Buildings Division Dane
<br /> Ill‘ipf%'!'A 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled In by Co.)
<br /> -,1 *.:741 .*; Madison,WI 53707-7162
<br /> "
<br /> Sanitary Permit Application Stale Trunsset ion Number
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this loon to the appropriate governmental unit
<br /> is requited prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(i(different than mailing address)
<br /> the Department of Safety and Professional Senies. Personal infommti Eld7rcry
<br /> purposes in accordance with the Privacy Law,a.15.04(1)(m),Slats. 691 CTH A
<br /> I. Application Information-Please Print All information
<br /> Property Owner's Name Parcel#
<br /> OCT o 5 2016
<br /> Dale& Lisa Reeves 0512-032-8530-0
<br /> Property Owner's Mailing Address Public Health MDC Property Locution
<br /> 708 E. Main Street Environmental Health Govt.Lot
<br /> City,State Zip Code Phone Number NW 'A, NW %,Section 3
<br /> Stoughton, WI 53589 (aisle one)
<br /> T 5 N; It 12 E or W
<br /> II.Type of Building(check all that apply) II
<br /> Ai Lot
<br /> M I or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name
<br /> . MP" Block* .
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City or •
<br /> CSM Number 0 Village of
<br /> 0 State Owned-Describe Use
<br /> 3760 0 Town or Albion
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> New System 0 Replacement System 0 Treatmenaloiding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. 1:1 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 P it Transfer to New
<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 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 Information:
<br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(s1) System Elevation
<br /> 300 0.4 750 750 90.7'&91.6'
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> 2
<br /> Gallons Gallons Units 1 E d.1 _ .„ .1...;
<br /> New Tanks Existing Tanks t g 2 t' li! 2—4 g
<br /> et LI in ., en il LI iT.
<br /> Septic or I folding Trosk 1000/300 1300 1 Dalmaray x
<br /> Dosing Chamber
<br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attacked plans.
<br /> Plumber's Name(Print) Plumber's Signature ,,,,......---- MKfit4PliD.Iumber Business Phone Number
<br /> A4044. RO5 Cti4k)ct,Lt.wi,
<br /> ce
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 91 1. sr-cute, ec-c..ii i 3 , ..51-0 t.4. hin 0 i Wt 55ss/
<br /> VIII.County/Department Use Only
<br /> 0 Approved CI Disapproved Perzil Fee
<br /> ,_ Date Issued Issuing Agent"rare Q.....,,k
<br /> s oo,
<br /> —
<br /> 0 Owner Given Reason for Denial OF .
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> Attach to complete plans fm-the system nstil submit to the County only on paper not less than II ID x It Inches In size
<br /> SBD-6398(it.I I/I I)
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