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County V <br /> .^11 Dane <br /> 4.1.4,,"94,;':;;.!, 1 Safety and Buildings'Division /Y� <br /> i ! 201 W.Washington Ave.,P.O.Box 7162 /' 1 <br /> 5aniierY permit Number(b be filled is Co. <br /> ; '....,,,.:::181, Madison,WI 53707-7162 <br /> by ) <br /> l3- ao/4, — DO3d3 <br /> Sanitary Permit Application Stec TnmtssetionNumber <br /> to accordance with SPS 38331(2).Wis.Actin.Code.submission of this farm to the apptopriale governmental unit <br /> is requited prior to obtaining a sanitary pencil. Nola Application forms for state-owned POWTS are submitted to Project Address(if difaerrt then mail' <br /> the Department of Safety and Professional Sereies. Personal information you provide may be used for secondary mC Wawa/ <br /> purposes in accordance with the Privacy Law,s.I/04(1 1(ml.Slats. <br /> 1. Application Informdoa-Please Print AU InfonastionR E C E I V E D Erb Road <br /> a <br /> Property Owner's Nome <br /> Parcel 0 <br /> Kenny&Pat Anderson 0607-2249501-0 <br /> Property Owner's Mailing Address OCT 13 2016 Property Location <br /> 112 N. Franklin Street priblic Near,Mac Govt.La <br /> Cam,State ZipCock Env'IhRittilittiffi Health SE <br /> Verona,WI 3 �, SE ,section 22 <br /> U.Type of Building 1 T 6 N 7 (circle one) <br /> K(check all that apply) Lot R R E or W <br /> ®I or 2 Faintly Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block 40 Acre Parcel <br /> 0 Public/Commercial-Describe Use <br /> 0 City or • <br /> ❑State Owned-Describe use CSM Number 0 Village of <br /> l l Town of Springdale <br /> iIl.Type of Permit: (Cheek only one box on line A. Complete line B If applicable) - <br /> A. <br /> ®New System 0 Replacement System 0 Treatment/Holding Tank Replocement Only 0 Other Modification to Existing System(estplain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Mary*Mamba 1 0 Pack Transfer to New List Previora Pnmit Murtha and Date Issued + <br /> Before Expiration 1 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground El 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 Pretreatmeta Device(explain) <br /> V.Dtspersal/1'reetment Area Inforomadon: <br /> Design Flow(gpd) Design Soil Appiication Rmc(gpdsl) 1 Dispersal Area Required(se. Dispersal Area Proposed(st) ( System Elevation <br /> 450 0.6 750 I 750 (I 97.5' <br /> Vt.Tank Infer Capacity in Total #of Manufacturer <br /> New Tanks Gailons Gallons Units B z <br /> Esi>rj5 Tanks g 1 U -, <br /> e.0 rn A cn a <br /> sips`°/.Haldiva Talk 1000 r <br /> 1000 1 Dalmaray x <br /> Dosing Omaha 600 600 <br /> - _ 1 Dalmaray x <br /> ViL Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shorn on the attacked plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> �`�the A.\y J J tl\4i (-40. I as 7 sa.5 I <br /> og 1gs-7q <br /> Plumber's Address(Street,City.Slate,Zip Code) 7 6 C? <br /> I 33 O Fr y kZ Rd . Ve.e-0 ti 4 , 1/4,v: 5359 3 <br /> VIIL County/Department Use Only <br /> ❑Approved I ❑Disapproved I Penult Fee . 1 Data Issued issuing Agent Sig nature 0/ki ` �6 O Owner Otven!lesson for lenisl 1 I( by //9/ <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> Attack to Complete pines for the system seal submit b lac County aaly on paper not less then a Ina s I l lacks In she <br /> SBD-6398(R.11/I I) <br />