Laserfiche WebLink
,y4L`U17x1-. <br /> . County <br /> s` � � ' Industry Services Division DANE ,b J <br /> , „r y • ,.�- 1 '00 E. Washington Ave., P.O. Box 7162 • Sanitary Permit Number(to be filled in by Co.) <br /> 'r;;F.` _;0 - ' Madison, WI 53707-7162 <br /> - �to�.0 t 3— 4 0 /6- op 33. <br /> Sanitary Permit Application State Transaction Number <br /> In 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.Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information RECEIVED E® COUNTY ROAD_I / <br /> Property Owner's Name Parcel# <br /> ERIK& CATHERINE RANHEIM / OCT 2 7 2016 0706-204-8003-0 <br /> Property Owner's Mailing Address Property Location <br /> Public Health MDC . <br /> 3900 MERIDIAN OR. Environments! Hcyltf, NE /4, SE /<, Section • 20/ <br /> City, State, Zip Code Phone Number <br /> VERONA, WI 53593 T 7 N,R 6 E <br /> II.Type of Building(check all that appl Lot • Subdivision Name <br /> fig/ <br /> 1 or/2 Family Dwelling—Numbero :edroon . 4 i Blcck# <br /> ❑Public/Commercial—Describe Use CSM Number ❑City of <br /> ❑State Owned—Describe Use ❑Village of <br /> Cl'I of VERMONT <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. C9'New fP System / ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all t t apply) - <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground At-Grade y❑Mound>24 in.of suitable soil ❑Mound 55 24 in.of suitable soil • <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 / 0.6 / 1000 1 1000 99.0' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 11-' 0 <br /> u o <br /> New Tanks Existing Tanks w .0 o a, an <br /> a o 2 .m ° in <br /> n. U cn �, rn iL o E <br /> Septic or Holding Tank 1600 / 1600 2 . CREST X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber>Signature MP/MPRS Number Business Phone Number <br /> CL/C.-(t(-v' l✓ Als. 4✓ 6✓1&1.- 227-7 l3 Cop 2/2 2 6 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V .County/Department Use Only <br /> Approved ❑Disapproved Permije / Date issued / lssuin. t Sim ature <br /> ❑Owner Given Reason for Denial $ 1�b !O jz8//4 g.ilay <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> TeeT 4,T G 17e- s/7'6- .fivd /fLee+ /S Pee- <br /> 7- ,PeArovraope /.t./ /Tl <br /> ,N41u,{t.4�. Co.vpBrio.,, _ A/c) PiSceig.-44srici -1 ,oviot P.otcT/a.4; 6xe.e_v.e_Tides o,e ✓E,we <br /> T i?t t'P='G Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in size <br /> SBD-6398(R.08/14) <br />