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RELtivtu <br /> SEP 21 2016 SCANNED <br /> .` ,N County <br /> (0:.''':!.y .' Public Healtt MDC Safety and Buildings Division Dane A tom. <br /> Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in Co.) <br /> ,' i g '.`' Environmental i-�I�'t 9 <br /> S�: rt Madison,WI 53707 7162 <br /> ,,, ' s r, )3 -.eat (0- body <br /> �, State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 38331(2),Wis.Adm.Code,submission of this fomt to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note Application forms for state-owned POINTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safely and Professional Sc vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m).Scats. Hillcrest Lane <br /> I. Application Information—Piense Print All information <br /> P Owner's Name Parcel N <br /> Joshua Rounds,Amanda Warriner 0509-2724067-7 <br /> Property Owner's Mailing Address Property Location <br /> 228 State Street Govt.,Lot <br /> City,Stale I Zip Cade° Phone Number ,,,-SW rs, NW •Y.Section 27 <br /> Oregon,WI 5357 (circle One) <br /> g s 53 5 T 5 N; R 9 E or IV <br /> li.Type of Building(cheek all that apply Lot ft <br /> l I or 2 Family Dwelling-Number of Bedroo <br /> 4 ' 7 Subdivision Name <br /> • �' Block IS r7Assessor's Plat of the Town of Oreg. <br /> ❑Public/Commercial-Describe Use ❑City or <br /> CSMNumber ❑Village of <br /> o State Owned-Describe Use <br /> ®To Oregon <br /> Town of g <br /> iII.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A' M New System ❑Replacement System ❑Treatment/tickling Teak Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 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 POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound>24in.of suitable soil Fi Mound<24 in,of suitable soil <br /> ❑Molding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/TreatmentArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(st) Dispersal A (s ,,,,System Elevation <br /> 600 1 r'c 6 1 t' ' 6 . �..2 100.8' <br /> VI.Tank Info 'Capacity in ITitnl g of Man urer ' B 8 <br /> Gallons Gallons Units . E u <br /> L z V� <br /> New Tanks Existing Tanks R tJ y.1 g E V a. <br /> Septic ar Holding Tnnk 1250 1250 1 Crest x <br /> Dosing chaa,ber 750 750 1 Crest x <br /> Vil.Responsibility Statement-I,the undersigned, me responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Signature I MP/MPRS Number Business Phone Number <br /> Trak)15 Plumber's Address(Steed,City,Stu q Zip Code) <br /> 7411 I f 714143/ o BeiL /4-- "`°�-.... G---3-54A5„ <br /> V I1.County/Dena eat Use On y . / _____ <br /> ved ❑Disapproved Permit Fee Date Issui'ns Agent .sure <br /> 0 Owner Given Reason s tet,.(k i. L/6,Reason Tor Denial IlIP.-. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for tie system and submit to the County only na papa'oat less than II to a 11 Inches to size <br /> SBD-6398(It.11/1 I) <br />