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�6t RECEIVE County <br /> !°{ =�?~c Safety and Buildings Division Dane <br /> i+ Ds a' 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(lo be Pilled in by Co.) <br /> .e p 5's i OCT 17 2016 Madison,WI 53707-7162 <br /> es>' <br /> �fii4L Public Health Mnr <br /> Ervggii'If aPti t Application State Tronsection Number <br /> In accordance with SPS 383 2)(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obaining a sanitary permit.Note.Application forms for state-owned POWTS ere submitted to Project Address if different than mailing address) <br /> the Department of Safety and Professional Sers ies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy taw.s.15.04(1)(m).Stats. <br /> Autumn Pond Trail <br /> I.Application Infornmtou-Please Print All Information <br /> Property Owner's Name Parcel <br /> Whitney&Helen Hite 0808-312-2079-0 <br /> Property Owner's Mailing Address Property Locution <br /> 1230 N.High Point Road <br /> Govt.Lot <br /> City,Slate Zip Code Phone Number NW '. NW v.,,Section 31 <br /> Middleton,WI / 53562 T 8 +Nc R 8 (circle one) <br /> 11.Type of Building(check all that apply) ( Lot I <br /> li I or 2 Family Dwelling—Number of Bedrooms 5 19 Subdivision Name <br /> Meek Autumn Pond <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Usc CSM Number ❑Village of <br /> M Town of Springfield <br /> III,Type of Permit: (Check only one hap on line A. Complete line B if applicable) <br /> A. )New System ❑Replacement System <br /> y ep ❑Tralmentfliokfing Took Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Pro-toil Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dote Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> li Non-Pressurized In-Ground ❑Pressurised In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Mink ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Trentment Area Information: <br /> Design Flrnv(gpd) Design Soil Application Rate(gpdsl) Dispersal Arca Required(sl) Dispersal Area Proposed(s() System Elevation <br /> 750 0.4 1875 1896 77.9,79.3,80.8,82.1' <br /> VI.Tank Info Capacity in Total n of Manufacturer <br /> Galleon Gallons Units — <br /> New Tanks P aline.Tanks C U E _ <br /> - <br /> n <br /> �U r w i=U s <br /> septic m t o am/rank 1000/600 1 1600 1 Crest x <br /> Dosing Chamber I I <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> pIum,Ficr s Name(Print) PlurtdrO'rSignature Ml'/MPItS Number Business Phone Number t <br /> p A -y - <br /> Plumber's Address(Strcct,City,Stale,Zip Code) <br /> /Z} t :? /' et <' ) / ) '' <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing cn Appmved ❑Disapproved k.S. m/re proir_ <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovnI/Reasons for Dtsnpprovoi t <br /> Attach to complete plans for the intent and submit to the County nnly rat paper nal lass than A tr•-5 I I Inches In slue <br /> SBD-6398(R.11/11) <br />