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t.f.�' �s County <br /> /Al,„ Safety and Buildings Division Dane <br /> ',i`(i v 't,: R 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> ,s; 3P rl Madison,WI 53707-7162 <br /> ,.` l .}, y i' S— ap j{o — 00 3?3 <br /> Sanitary Permit Application. State n <br /> lo 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. Nate:Application forms for state-owned POINTS ore 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.I5.04(1)(m).Scats. Erb Road <br /> I. Application information-Please Print All information E C E J` E(l <br /> Property Owner's Name [ V L! Parcel 0 <br /> > C(t<r 0607-224-9501-0 <br /> Kenny& Pat Anderson t..,:, Gv OCT 1 8 2016 <br /> Property Owner's Mailing Address Property Location <br /> 112 N. Franklin Street FJblt Health MDC Govt.Lot <br /> City,State Zip Code Envi'8 t114110 Health SE %, SE IA.,Section 22 <br /> Verona, WI -5393 6 7 {circle one) <br /> 11.Type of Building(check all that apply) Lot# T N; R E or W <br /> ®1 or 2 Family Dwelling-Number of Bedroom 3 Subdivision Name <br /> Block# 40 Acre Parcel <br /> ❑Publie/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> El Town of Springdale <br /> iiI.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. ®New System y ❑Replacement System ❑7reatmentlHokling'11mk Reptac«neni Only 0 Other Madititation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POW TS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground El At-Grade ❑Mound>>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Aren Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> 450 0.6 750 750 97.5' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a E ii o <br /> New Tanks pxersting Tanks U u S u - I. i3 <br /> d:t� m to r=O a. <br /> Septic nol4ol3LtgTank 1000 • 1000 1 Dalmaray x <br /> Dosing Chamber 600 "'s' 600 1 Dalmaray x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POV.'TS shown on(lieu tioclied plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> . INNb ANNNI -,a a t14 (-1',. .11,4---- 7 S's2' 6 ac Ic-l16 6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only �`- <br /> }� Permit Fee Date Issued Issuing tSi <br /> proved ❑Disapproved 1 ... J <br /> ❑Owner Given Reason for Denial $ 14.4 /0./7_ ' 6 `r. /a�e _ i <br /> IX.Conditions of Approval/Rensons for Disapproval <br /> PA1�- oil 64/4.DE filE AW — <br /> .01'64 17/x€ jc•?0i4 ,l' t6 COA1,4C? A; •lam« 6 -C-A'1 fr ' ' .41 <br /> MN al4/a4-- "etc. <br /> Attach to c mptete plans for the system and submit to the County only nn paper not less than 8 to s It Incites In size <br /> SBD-6398(R.Il/11) <br />