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- -County <br /> 1�tl; *. Safety and Buildings Division Dane 71 h <br /> (It ds xi,'S,.'�� 201 W.Washington Ave.,P.O.BOX 7162 Sanilary Permit Number(It,be tilled in by Co.) <br /> ' ' ,r. `d Madison.WI 53707-7162 <br /> � .` ` ' /3-do/6- co 3`{ <br /> Sanitary Permit Application State Trunsection Number <br /> In accordance with SPS 38321(2),Wis..Adm.Code.submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a senkary pemdt.Nate Applieati bmtucd to Project Address(if diflerwo than mailing orklress) <br /> the Department of Safety and Professional Saves. Personal in ecoad«y <br /> purposes In oec«daace with the Privacy Law,s.I5.O4(I Xm).St <br /> L Application Infisresnitluji-Please Punt All information <br /> Property Okrner'sNome OCT 2 1 1016 Parcel a <br /> Charles&Jennifer Ripp 0908-361-8460-8 <br /> Property OWSIc'S Mailing.Address t'uc Health MDC Property Location <br /> 6645 Ripp Drive Environmental Health <br /> Govt.Lot <br /> Cdy,Stale <br /> Zip Code Phone Mamba NE t5, NE )4,Section 36 <br /> Dane,WI _ 53529 T 9 N, R 8 (circle one <br /> 11.Type of Building(check all that apply) Cold <br /> NI or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Nome <br /> Block.°. <br /> ❑Publlc/Comnereial-Describe Use <br /> ❑City of • <br /> ❑Slate Owned-Describe Use <br /> CS Number ❑Village of <br /> 9003 ®Town of Dane <br /> III.Type of Permit:(Check only one hex on Rae A.Complete line B If applicable) <br /> 'I' ❑New System Replacement ❑TrmlmenUtoklte g Took Only <br /> ❑Other MndiOmlion to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Rnvimt <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> I V.Type of POINTS System/ComponenNDevtcm (Check all that apply) <br /> El Nompmsurhed In-Omsnd ❑Pressurised In-Ground ❑At-Grade ❑Monnd>24 in.of suitable soil ❑Mound<24 in.of suitable soli <br /> ❑Holding Tank ❑Other Dispersal Compwrmt(explain) ❑Pretreatment Devise(explain) <br /> V.DtspersaVTrentrnent Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdst) Dispersal Area Required(s0 Dispersal Area Proposed(s0 System Elevation <br /> 450 0.5 900 978 102.4',103.1',106.0' <br /> VI.Tank info Capacity in Tote) 4 o Manufacturer <br /> Options Gallons Units t Si S$ R <br /> New Tanks Existing Tanks Ct 5X 0 g °1 <br /> tt rJ inn w to IZ t2 6 <br /> septa«rloidog Task 1000 1000 1 Meade X <br /> Onsins Chamber 650 650 1 Meade x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POUTS shown on the attached plans. <br /> Plumber's Nome(Print) Plumbef s Lure MP/MPBS Number Business Phone Number <br /> Plumber's (Sued,City.Sale,Zip Code) <br /> — _ <br /> I r5 -k— ftI x�1 itt, wi `-��T-�(1 <br /> ViII.County/Department Use Only <br /> ❑Approved ❑Diagnosed <br /> Permit Fee Date ironed/It /Issuing- S ,• <br /> ❑Owner Given Reason for Denial S Li' ! --- 10/2( iLGI'I e# . <br /> IX Conditions of Approval/Reasons for Disapproval / .a ' <br /> C <br /> ,'xrsnA'oc 77fit,g4 7z' ere. ?4,.a►reb e- /' 47ô r',eieir2.. <br /> TP Fjry7-c- /,(vs ' 77oK/. <br /> Anacb to complete pious for Ilse system end submit to the Comity may on piper not less than 0 1111 11 Inches in sire <br /> SBD-6398(R.(Iii 1) <br />