|
,i�:r ie. County h,' t7
<br /> /,• )'�1. •`a~ Safety and Buildings Division Dane
<br /> �...,,,_..•_,..,, ''�� Washington anitary Permit Number(to be Stied in by Co.)
<br /> r p$i :r. 201 W.Washln ton Ave.,P.O.P O.Box 7162
<br /> ; P�
<br /> I"i Madison,WI 53707-7162
<br /> ‘..,,N..1
<br /> v?,1 % '' / S —fie)1(O ° 0�a" 316--
<br /> Sanitary Permit Application State Transact ion Number
<br /> Is accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit
<br /> is requited prior to obtaining a sanitary permit. Nate:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
<br /> the Department of Safety and Professional Semies. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats.
<br /> I. Applicationlnformation-PleasePrintAllInformation ,,uedes Lane
<br /> Property Owner's Name LL , :,-y,,,, Parcel H
<br /> William&Anne Lobenstein ` •' r:`' 0812-344-9045-0
<br /> Property Owner's Mailing Address DEC 08 2018 Property Locution
<br /> 3272 Deerfield Road P, cove Lot
<br /> City,State Zip Code E'Nbri)I eith till. SW :4, SE w.Section 34
<br /> Deerfield,WI 53531 @ ''ii-tealhh (circle one)
<br /> II.Type of Building(check all that apply) Lot# T 8 N; R 12 E or 1v
<br /> ®I or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Name
<br /> Block II
<br /> ❑Public/Commercial-Describe Use
<br /> ❑City of
<br /> ❑State Owned-Describe Usc CSM Number ❑Village of
<br /> 10439 ID Town of Medina
<br /> iII.Type of Permit•. (Check only one box on line A. Complete line B If applicable)
<br /> A. El New Replacement System ❑R System y m ys, ❑TreatmantnioldngTttnk Replacement Oniy ❑Other Modification to P.xtsiing System(explain)
<br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dula 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 ❑Al-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
<br /> ❑Molding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
<br /> V.Dispersal/Treatment Area information:
<br /> Design Flow(gpd) Design Soil Application Rale(gpdsp Dispersal Area Required(st) Dispersal Area Proposed(s!) System Elevalion
<br /> 600 0.4 1500 1500 100.0', 102.0'
<br /> VI.Tank Info Capacity in Total #of Manufacturer
<br /> Gallons Gallons Units ` _U
<br /> Nov Tanks Existing Tanks e 8 5 �+ d
<br /> a U iii r-n r=4 a
<br /> Septic oollaldiogTnnk 700/550 1250 1 Crest x
<br /> Dosing Chasnbto
<br /> VII.Responsibility Statement-1,the undersigned,ass ,. esponsibitlt•for installation of the POWTS shown on the attached plans.
<br /> Plumber's Name(Print) 1 P .i,, Signal *jai,'MP/MPRS Number Business Phone Number
<br /> t`-oi..L.+u ,>..rL._.. I ..- z7tietC? , ?J.__ ' IP.
<br /> Plumber's Tess(Street,City,Sate,Zip Code)a LI erte,..e-,,,/ ie d 1-A,,,,c. /(4e.-
<br /> VIII.County/Department Use Only
<br /> XApptwed ❑Disapproved
<br /> Permit Fee rDateissued Issuing Agents' ore
<br /> ❑Owner Given Reason for Denial S 7 4/ '' (2..4-20/6
<br /> Ni -
<br /> IX.Conditions of Approval/Rensons for Disapproval
<br /> Attach to cnmpiele pions tar the system amt submit to the County only on paper not less than It tG s II Inches In size
<br /> SBD-6398(R.11/I I)
<br />
|