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County <br /> Safety and Buildings Division Dane %5) <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number Ito be alibi in by Co.) <br /> ,P 8 � Madison,WI 53707-7162 <br /> ' d0/6 OD 33`{ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining o sanitary penniL Note Applieoti r••-••.-. • t•.. submitted to Project Address fir different than smiling address) <br /> the Depormrent of Safety and Professional Snits.Personal in u <br /> they <br /> purposes in oecordana with the Privacy Law,s.15.04(1)(mi.St <br /> I.ApplicationInformation-Please Print All InIormadon <br /> Property Owner's Nome OCT 21 2016 l'aeeld <br /> Charles&Jennifer Ripp 0908-361-8460-8 <br /> Property Owner's Mailing Address runbC Health MDC Property Location <br /> 6645 Ripp Drive Environmental Health <br /> Govt.Lot <br /> City,State Zip Coda PhoneNUmber NE A, NE u,section 36 <br /> Dane,WI 53529 T 9 N- R 8 (erreeone) <br /> II.Type of Building(cheek all that apply) Lot# <br /> ®I or 2 Family Dwelling-Number or Bedrooms 3 1 Subdivision Nome <br /> Block k <br /> ❑Publie/Commereiol-Describe use <br /> ❑City or • <br /> ❑State Owned-Describe Use _ CSMNumbv ❑VillageoC <br /> 9003 GI Town or Dane <br /> III.Type of Permit:(Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System )Replacement System ❑Treatment/Holding Took Replacement Only Existing (explain) <br /> ❑Other Modification to Extsti System(e. lain <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Traufer to New <br /> Lisl Previous Permit Number and Late Issued <br /> Beare Expiration Owner <br /> IV.Type of POWTS System/Component/Device; (Check all that apply) <br /> M Non-Pressurised In-Ground ❑Pressurised In-Ground 0 At-Grade ❑Mound>24 In.ofsultobk soil 0 Mound<24 in.orzudable soil <br /> ❑Holding Tank ❑Other Dispersal Component(avploin) ❑Pretreatment Device(explain) <br /> V.DisperseVrreatn_setit Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(at) Dispersal Area Proposed(sl) System Elevation <br /> 450 0.5 900 978 102.4',103.1',106.0' <br /> VI.Tank Info Capacity in Total g of Manufacturer <br /> Gallons Gallons Unbs 9 o'S v <br /> Nor Talks Existing Tanks B X aZ, . B 4. <br /> 'vi b yr r=O n. <br /> Septic ar Molding Tank 1000 1000 1 Meade x Dosing amber 650 650 1 Meade x <br /> VII.Responsibility Statement-1,the uaderstgned,assume responsibility for installation at the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Pimnbe nature MMMPRS Number Business Phone Number <br /> i-ft � ,--� -�-t a 751-?A ten-"1Ka�- r�5 <br /> Plumber's (Street,City.State.Zip Coda) <br /> VV'7S6') M k t . ed (U f O t e i e [Lf 4'-)". <br /> VIII.County/Department Use Only <br /> ❑Approved ❑Disapproved <br /> Pencil Fee Dole Issued Issuing S': • <br /> ❑Owner Civen Reason ror Denial s �� .� l o]2 <br /> IX.Conditions of ApprovatfReasons for Disapproval ! <br /> 1 L' F;;A∎4 persfec..77d�r.�. <br /> Attach to eomplere plans f o r the system amt submit to Ilse County only on paper not less then flax I t inches In she <br /> SBD-6398(R.1 111 I) <br />