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.4:4 v: <br /> ft County <br /> i:;•; � Safety and Buildings Division Dane <br /> ('r 4.3 'i: ,:�' PW.Washington Ave.,P.O.Box 7162 Sanitary (to = by <br /> 9 Sanii Permit Number to be tilled in Co.) <br /> ,e� SP"'•r' �i .. Madison,WI 53707-7162 <br /> ` tl3 au17-0o00S <br /> Sanitary Permit Application stoic 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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Serries. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law.s.15.04(1)(m).Slats. 1385 Storytown Road <br /> I. Application Infornuttion-Please Print All Information <br /> P,ro `Owner's Name Parcel <br /> 4"-Mike Rezac, Kathy Debner '1'7- i...---- <br /> .r " 0509-053-9860-1 <br /> Property Owner's Mailing Address Property Locution <br /> 9 Piedmont Court Govt:Lot -,' <br /> City,State Zip Code Phone Number 1 SE SW %,Section 5 <br /> Madison,WI 53 1 (circle one) <br /> II.Type of Building(check n11 that apply)/ Lot# T 5 N; R 9 E or W <br /> ®I or 2 Family Dwelling-Number of Bed 3 / L-71" Subdivision Name <br /> ' Dlock# <br /> 0 Public/Commercial-Describe Use ❑City Dr <br /> ❑Slate Owned-Describe Usc CSM Number ❑Village of <br /> ,•,.. 799 l Town or Oregon <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. New System 0 Replacement System ys p ys ❑Treatment/Holding Tank Replacement Only ❑Other Moditicatlon to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date 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 lid At-Grade 0 Mound>>24 in.of suitable soil ❑Mound<24 in.ofsuitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersnl/Treatment Area Information: <br /> Design Flow(god) Design Soil Application Rate(gpdsl) Dispersal Area Required(si) Dispersal Area Proposed(si) System Elevation <br /> 1-460 ✓''0.6 ✓ 750 ,✓' 750 96.8' <br /> VI.Tank Iafo Capacity in Total N of Manufacturer , <br /> Gallons Gallons Units s 2 `o 1 o L.NI ell,Tanks Existing Tanks �eQQ a " `may a <br /> 0.8 Ai so LtJ E. <br /> Septic or Holding Tnnk 1000 1000 1 Crest x <br /> Doing Chamber 600 600 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu s Signet `e MP/MPRS Number Business Phone Number <br /> (� S 5t _"_`�',‹-.7� /al-Z-°2- LI?9 7b/Y <br /> Plumber's Address(Street,City,State.Zip Code) <br /> 781 C: /4-614'91 .//=�r1. <br /> VI I.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee <br /> -e Date 1 ed Instil _Agcnt5ignatu t la` <br /> 0 Owner Given Reason for Denial S io l Li n✓ f • /+err- T c 1 <br /> IX.Conditions of Approval/Reasons for Disnpprovnl <br /> 2 <br /> Attach to complete plans for the system and submit to the County only on paper not Ices than II tots II Inches In size <br /> RECEIVED <br /> SBD-6398(It.I t/I 1) <br /> JAN 17 2017 <br /> Public Health MDC <br /> Environmental Health <br />