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• <br /> -r...--.7,-,,,:,-; County �. ' <br /> l> , � Safety and Buildings Division Dane 3 8 <br /> g 147-i,...3'„'.! ,''`* 201 W.Washington Ave.,P.O.Bo%7162 Sanitary Permit Number(to be filled in by Co.) t t <br /> `� rl Madison,WI 53707-7162 i;z `� <br /> t S s, t Cut tF <br /> TI e-�_- 3•20i <br /> via r. �, <br /> Stale Transaction Numher 3 <br /> !Pr- . Sanitary Permit Applica ' � <br /> to accordance with SPS 38311(2),Wis.Ada.Code,submission of ibis form 1 't: s 1`, <br /> is requited priority obtaining a sanitary permit.Nolo Application fauns for stale-owned POW TS ore submlue to Project Address(if different than moiling oddness) ) to <br /> the Department of Safely and Professional Scrvics. Personal information you provide may be used for secondary <br /> I.Application in accordance with the Pr Pl o LeP,i 15.0401(m).AU Information Sacs. RECEIVED Bakken Road <br /> I.Applicotionloformntion-PigrsePrintAUlnCormatioa <br /> Property Owners Name V/ Parcel <br /> Darin Connor C/O Sylvester Sutter AU6 1 7 1016 1 0607-101-8081-0 <br /> Property Owner's Mailing Address Property Location <br /> 8579 Bakken Road - Public Health Mnr Govt.Lot <br /> City,State • . .2ipCodc Erivirt'fPR/4ETkS1 Health `/e„---IrE Vti NE i,Scttton 10 <br /> Mt.Horeb,WI 53572. (cite one) <br /> T 6 N; R 7 Eor W <br /> II.Type of Building(check 1111 that up y) ---�' Lot S <br /> I or2 Family Dwelling-Number of Bey) errs 3 Subdivision Name <br /> ® <br /> Block' 4.67 Acre Metes&Bounds Parce <br /> ❑Public/Commercial-Describe Use ❑City or • <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Usc rin dale <br /> ®Toun of 9 <br /> III.Type of Permit: (Check only one hay on line A. Complete line B If applicable) <br /> A.y j New System ❑Replacement System ❑TreotmmtHoldingTank Repincemml Only ❑Other Modiricatron.to Existing System(explain) <br /> B. ❑Permit Renewal 13 Permit Revision ❑Change or Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiation Owner • i'; <br /> IV.Type of POWVTSSystem/Component/Device: (Cheek oil that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ®Mound>24 in.of suitable sal ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/TreatnrentArea Information: <br /> Desigr.Rnw(gpd) Design Soil Ap�on Ralc(gpdsfl Dispersal Area Required(sr) Dispersal Area Pypposed(si) System Elevation <br /> 450 [�,Co 350--lr`3G p584 f 98.9' <br /> VI.Tnnlc Info Capacity in 'Total ;+of Mans actvrer <br /> Gallons Gallons Units ,o 9 . °- <br /> Ness Tanks Eaistinc Tanks g 2 3 <br /> r.U N w C ic O rs. <br /> SrpticorttotdingTmd: 1000 1000 1 Dalmarav x <br /> Dosing Chamber <br /> 600 600 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the PUNTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP(MPItS Number Business Phone Number <br /> ---[`tit..o-kh y J 3-4e_ y .3:x159.5 60x-8y5.7t(6t <br /> _. ..............__._...._.� <br /> Plumber's Address(Sired,City,Smile Zip Coder) ..- <br /> 1 3 3 CI Fµ,$ Rrk• Ve-re•v,,, Lk.'i%;5.3593 ,,, <br /> VIII.County/Department Use Only / i....„______, \ <br /> Permit Fee/ Date 1 Issuing eat SignaturrrS�S -,-% <br /> paved ❑Disapproved � L �G t i j I <br /> ❑Owner Given Reason for Denial 5/d V ''� `•-� / /S� f I` / <br /> IX.Conditions of Approvol/Rrnsons for Disapproval ..---- ' If <br /> si <br /> Attach In complete plans for the.system and so halt. the County only on paper not los than a sin 11 inches In she <br /> SBD-6398(R.11/I I) <br />