Laserfiche WebLink
,. • ,,, 4EEIVED <br /> County <br /> s 1 ,Y} <br /> ��%1✓' ��� �, ,, �- �0.�° Safety and Buildings Division Dane �!' t <br /> (If `0 `` •, OCT 2$ )a 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Vol - . PSr•4; Madison,WI 53707-7162 <br /> q‘ -_, / Public Health MDC i 3 _ -o i C (204i q <br /> ?;tzAfir. Environmental Health <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383?1(2),Wis.Mm.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 POWTS 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.15.04(1)(m).Scats. CTH D <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel H <br /> Dan Kok, Sara Schlough 0509-081-8085-t) <br /> Property Owner's Mailing Address Property Location <br /> 2921 Camp Leonard Road Govt.Lot 3 <br /> City,State Zip Cole.-\ Phone Number NE �1,, NE y,, Section 8 <br /> Mcfarland,WI �,..-' 53558 T 5 N; R 9 (circle a or W <br /> II.Type of Building(check nil that apply) / Lot H <br /> ®I or2 Family Dwelling-Number or Bedrooms 3 3 Subdivision Nome <br /> Block H <br /> ❑Public/Commercial-Describe Use ❑Cily of • <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 13475 ®Town or Oregon <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement S Y slam ❑TreatmcnU!loJdin g Tank Only <br /> ❑Other Modification to Existing System(explain) <br /> List <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS SystcmlComponentfDevice: (Check nil that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound 24 in.or suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Infarnintion: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Required(st) Dispersal Area Proposed(s() System Elevation <br /> 450 �' .-°0.4 A/1125 1134 94.2',95.2', 95.8' <br /> VI.Tank Info Capacity in Total H of Manufacturer <br /> Gallons Gallons Units °�g a�_ cs <br /> ii New Tanks Existing Tanks C ..g, i3 <br /> � c:U y U�O E.C) a. <br /> t or Holding Tank ., 1000 1000 1 Crest X <br /> Dosing Chamber 600 600 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of die POSITS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signal ltlh(tvMPRS Number Business Phone Number <br /> Bober?' Ev elf-501 %ALI...de/74 ,-,9--blig ee# T75--0102 4Z7 <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> SAfs'.5- I--n calm <br /> V II.County/Department Use Only / "`---- <br /> Permit Fee Date)saved Issui, Agent Si '•..u� ' �\ <br /> proved ❑Disapproved " <br /> ❑Owner Given Reason for Denial S 4 f «✓I 16 % . . - <br /> IX,Conditions of Approval/Rensons for Disapproval / r � — ' �---'" <br /> Attach to complete plans f o r the system nail submit to the County only an paper not less than 8 1a x I I aches In size <br /> SBD-6398(IL t I/l 1) <br />