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AUG 2 0 2008 U N"— c„. •..I i <br /> 17 ChK- qt-1 ai <br /> Lu.— <br /> Public Health MDC <br /> .!. ..^..,■:.-1,... :ith Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> scons I n Sanitary adison,WI 53707-7162 Permit Number(to be filled in by Co.) <br /> Department of�� 51SII1 <br /> Sanitary Permit Application 'State Transaction Number <br /> In accordance with s.Comm.13.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different tbannatiing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.04(1Xm),Sum. Koshkonong Road <br /> I. Application Information-Please Print All Information _ <br /> Property Owner's Name Parcel d <br /> Darren&Patricia Winkler 0612-212-8005-0 <br /> Property Owner's Mailing Address Property Location <br /> 331 Meadowlark Circle <br /> Govt-Lot <br /> City,State - Zip Code Phone Number NE v, NW v.,Section 21 <br /> Deerfield,WI 31 764-1001 (circle one) <br /> U.Type of Building(check all that app Lot it T 6 N; R 12 E or W <br /> CV 1 or 2 Family Dwelling-Number of 4 1 Subdivision Name <br /> Block I <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 12104 a Town of Christiana <br /> III.Type of Permit: (Cheek only one box on line A. Complete line B If applicable) <br /> A' Q New S ystem ❑R ep lacement System <br /> ❑Treatment/Holding Tank Replacement Only 13 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List woes Permit Number and Date issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Devitt: (Check all that apply) <br /> Ut Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVfreatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 600 0.4 1500 1500 99.0' <br /> VI.Tank Info Capacity in Total I of Manufacturer <br /> Gallons Gallons Units I u <br /> New Tanks Existing Tonics Y gg B , <br /> 3; h T, A a.3 ii. <br /> L <br /> Septic or Holdieg Teak 1250 1250 1 Crest x <br /> Mang Chamber 750 750 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for histalladon of the POWTS shown on the attached platy. <br /> PI ('s Name(Prnt}"`;\ Plumber' u e') MP/MPRS Number Business Phone Number <br /> Jac kLv� ii et_ -4t,^4 L ,."- _ 71-7)._ at^o,P --gi'_-ef <br /> Plumber's Address(Stre/et,City,State.Zip Code) / <br /> yin (VI /?�'PTt Q S 1, L 41-2- S'�S'<S'tj� <br /> VIII.Conn /De•artment'Use 0 . ..� <br /> pproved ❑Disapproved Permit Fee Date Is . • In •- f,�� r et Attli❑Owns Given Reason for Denial $ ' 6,-4"-" L <br /> IX.Conditions of Approval/Reasonn for Disapproval <br /> Attach to eeapkte prom for He system sad submit to lathe County only on paper not tae than!to s 1!Inches In she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />