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County <br /> i D Industry Services Division DANE ,,�eV\ <br /> -, I <br /> F 4 400 E. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> 1: °J Madison, WI 53707-7162 <br /> 13— date - coor. 48 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note.Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. I5.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information ERB ROAD <br /> Property Owner's Name Parcel# <br /> BENJAMIN GEISSAL& LINDSAY ROPELSKI 1 0607-274-8470-0 <br /> Property Owner's Mailing Address I Property Location <br /> 2816 SYLVAN AVE. NE '4. SE /J. Section 27 <br /> City. State, Zip Code I Phone Number <br /> MADISON, WI 53705 I 608 577-1945 T 6 N. R 7 E <br /> 'I I.Type of Building(check all that apply) _ ° \ Lot# 3 Subdivision Name <br /> CIY or 2 Family Dwelling-Number of Bedrooms 3 Block# <br /> O Puhlic/Commerciai-Describe Use CStM Number 0 City of <br /> 10 State Owned-Describe Use —__--_ 9748 0 Village of <br /> I21 vvn of SPRINGDALE <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I�'New System ❑ Replacement System 0 Treatment/Holding Tank Replacement Only ■ ❑Other Modification to Existing System(explain) <br /> i <br /> B. ! List Previous Permit Number and Date Issued <br /> ' 0 Permit Renewal 0 Permit Revision � ❑Change of Plumber ❑ Permit Transfer to <br /> ', Before Expiration 1 j New Owner 1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> O Non-Pressurized In-Ground ❑ Pressurized In-Ground Ca'At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<_24 in.of suitable soil I <br /> 10 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)' <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) 1 Dispersal Area Proposed(st) System Elevation <br /> 450 i 0.6 ( 750 I 750 104.5' <br /> VI.Tank Info Capacity in Total #of Manufacturer I I t <br /> ' Gallons j Gallons Units " a ' <br /> j I New Tanks Existing Tanks I •3 &I u 5...; yi r' B. <br /> CJ in sl - 5; <br /> Septic oi.l tiling Tank 1000 1000 1 DALMARAY I X <br /> Dosing Chamber 600 I — r 600 1 DALMARAY I X <br /> VII. Responsibility Statement-I, the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) er's Si rat. MP/MPRS Number Business Phone Number <br /> SCOTT LOVELACE r 4.- 226-852 (608)465-3314 <br /> Plumber's Address(Street.City.State, tp Co <br /> LOVELACE PUMP COMPANY, INC., 9914 COUNTY M, ARGYLE, WI 53504 <br /> VIII.County/Department Use Only <br /> _ - <br /> ,pproved ❑Disapproved Permit Fee Date <br /> .+ Date Issued ` Issuii�• Age, Sin afp ire N <br /> ❑Owner Given Reason for Denial $ 1,4-"1 j 1-2-7 . 7 I /ikA/A„la ,/ <br /> IBC.Conditions of Approval/Reasons for Disapproval ls" T �, ��� D <br /> P297 1 Al G-RAPE i 77 - <br /> tN r-Tr,r �tT � co,tor7.Gr p � . ..._-_.._. <br /> R�� Fo1� S�/c ci ecf;irr JAN 2 6 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 3 I,12 x I I inches in size r ty:T.Hi@aIttt MSC <br /> SBD-6398(R.05/14) <br /> E?t',AK nmental Health <br />