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�+'- County J,,r w <br /> / f`5 � Safety and Buildings Division Dane ,Y, <br /> N!' :r:�.:.. a <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filial in by Co.) <br /> Spi-' •i SCAN "' Madison,WI 53707-7162 <br /> vi "'_ i3-• o lb- OC)3!{ <br /> Sanitary Permit Application State TmnsnetionNumber <br /> In accordance with SPS 353.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is inquired prior to obtaining a motley permit.Note:Application forms for state-owned POW IS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional w,a.1s. Personal Stun.ol(I E/iv ry <br /> purposes in oceorderee with the Privacy Law,s.15.g4(1)(ml.stets. II LL Glenway Road <br /> L Application Information-Please Print All Information <br /> Property Owns s Name OCT 0 3 2016 Parcel <br /> 1/Joshua&Toni Wills e2 0509-152-9850-0 <br /> Property Owner's Mailing Address Public Health MDC Property Location <br /> 717 Willow Run Street Environmental Health Govt:Lot <br /> City,State Zip Cody e Phone Number �,/SE i,4, NW %,Section 15 <br /> Cottage Grove,WI ,, - 7 (circle one) <br /> T 5 N; R 9 EorW <br /> II.Type of Building(check all that apply Lot If /' <br /> iii II or Family Dwelling-Number of Bedroo - 3 - t,--' 2 Subdivision Name <br /> Block it <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ❑State Owned-Descn"bc use CSM Number ❑Village of <br /> L.713497 ®Town of Oregon <br /> III.Type of Permit (Check only one box on lion A. Complete line B if applicable) <br /> A' M New System ❑Replacement System ❑Treatment/tinkling Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Per Revision ❑Change of Plumber ❑Permit Transfer to Nov List Previous Permit Number and Dute Issued <br /> Permit <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device (Check all that apply) <br /> ❑Non-Pressurized tn-Ground ❑Pressurized In-Ground, ®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 Area Information: <br /> Design Flow(god) Design Soil Application Rete(gprkD Dispersal Area Required(sr) Dispersal Area Proposed(s)) System Elevation <br /> 450 0.6 750 750 96.8' <br /> ... VI.Tank Into Capacity in Total it of Manufacturer , <br /> Gallons Gallons Units a @ 8 T _ <br /> New Tanks Existing Tanks L c =t* e <br /> U h in iZ Ca ii <br /> a;s"'Win ra.k -1000 1000 1 Crest x <br /> Dosing camber 600 600 1 Crest x _ <br /> Responsibility,Statement-I,the undersigned,ass me responsibility for Installation of the POWTS shown an the attached plans. <br /> /)C&DKIC1-1 <br /> Phi S' urc MP/MPRS Number Business Phone Number <br /> C1a / 155Ltle 1.sO2oq-foo77 <br /> •'t'9.•'s Address(Sir et,City.State,Zip Code) <br /> 1-1415 SDfe. C-YC'- vr\or\ ..- 1 -311 tP' <br /> VIII.County/Department Use Only y'` <br /> Permit Fee Date Issui -gent S'';i, ._.�` <br /> Approved ❑Disapproved r_ / -.�� - ��, <br /> ❑Owner Given Reason roe Denial s 17 /O/�� ///J <br /> IX.Conditions of Approval/Reasons for Disapproval [[[ <br /> Al tack to complete plans for Ibe eaten end sehmit to the Caant•only on paper oat less than g IC s I I Inches In sloe <br /> SBD-6398(R.11/I I) <br />