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4'..�iiiTiev- County i <br /> �'%f' ! � Safety end.eulldings Division Dane ��','" <br /> P? Y~t--, 201 W.Washin ion O.'BOx`7162 <br /> ' z°$r''�`�'j j 9 &milary PerinirNumber(Io be filled In by Co.) <br /> I♦T 4'i- J:' Ave:,1 <br /> IA>, �FP' Madison WI 53707 7162 <br /> L,rsr$� 'fi% 1 <br /> ` � ' . 13- 40 1-7 <br /> n 5tuiaTmnme([on.Numlirr - <br /> Sanitary Permit Application , <br /> In accordance frith SPS•383:21(2) t4ls.`Adm.Code,submission afthis form to the appmprtate• overnineutaltili • . . <br /> is required prior to obinining a;sonitary permit Neic rlppllentlim forms forslate armed POW . are sttbr ttled to 'Project Address:11f different diun,melling'addi ss) <br /> the Department of Safety.and•Profcsehmal Servies..Pe6analinfmtnoiion you provide may be useii.forsceandtuq <br /> .purposes In orcordanee With'the Privacy taw,s.15.04(t)(mI.Slats. .. . ....._...__.. .. <br /> L Appllctitlmrlafarnlutlan-Pleiise.FrintAUlnformation OSIO Lane <br /> PropertyOnncr's Name pnreei n <br /> Marten Building&Design, Inc. 0911-194-4589-0 <br /> Property Owner's Mailing Address ISot..ty:Locotlon <br /> P.O. Box 64 Govt Lot <br /> City;State .Tip PliolieNumber SW ! , SE ..,,;section 19 <br /> Sun Prairie,WI 590 1 212-6934 • (circle one) <br /> II.Type of Ilulld)ng(cheeh.all that apply)f , Lot>p T. <br /> 9 N: J[ 11 Ear 1Y <br /> El i ar 2 Famiy Dn'elling-Number of Bedraoi 4 9 : SabdivMcai Name <br /> ptoek# • Lehman's Addition <br /> ❑Piddic/Cammeieial-Describe Use <br /> Chy.of. • <br /> . CSMNumber Villggeof......._..._.__........ <br /> ❑Slate Onacd'-DesaibeUsc <br /> K Toirt of• Bristol <br /> I1f.Type of Permit_(Cheek ollly.'Ode hos•on)Ire A. C.otnplete.lIna B If applicable) •A. ®:NetvS' .❑die laremenl`System <br /> ystuslt p ❑TrenaneatllloldargTualcRcplaccmea fQn)y ❑Other ModilicottanlotvislingSyslem(etpinin) <br /> B. ❑Permit Renewal ❑Permit Ilevision .-0 Change of Plumber ❑Permit Transfer to New. List Previous Permit Numbs and Date Issued <br /> _.. <br /> Before C^gdralion • p‘ti• <br /> IV.Type or POWTS SystemICOtnponcat/Devieet.-(Checknil Wntnpply) _ <br /> iI Nan-Pressurized In-Ground ❑Presurizedin-Ground ❑Al-Gzpde ❑Mound>2q in.of suitable sill ❑Maned<24 hi ofsultohlesoli. <br /> ❑Flolding Tank '0-Other Dispersal Componein,(csplain) .. . ❑.Pretrcaiutent Device(cipluin) . <br /> V..Dlspersal/TreatmentArea laformntlan: <br /> Design Flow to <br /> gn (gpd) Design Soil Appli�ioa.Rale(epds!) Otslxrsa!Arm Rignlrcd(sf} Dispersal Atra Propasa)(s() 5ysttett,Elewliaa <br /> 600 0.4 1500 1500 . 87.5', 88.4', 88.9' <br /> V1.Tanic Info •Capeelly in i Total #of Manufacturer <br /> •Gallons. Gallons Units a e <br /> Non Tanks Existing TnnI Lop' ha 2 .g <br /> Sgthc r 1nldb'gTalk 819/467 1286 1 Meade x <br /> [InnenOhm:Iber .650 — 650 1 Meade . x <br /> VIL RespansibilityStntement I,the undersigned,assuineresponsib(llty.for Installatian of the POWTSsitonn on the nitaehell plans. . <br /> Plumber's Name rint) Ir Plumber's 5ignaltnc' MP/MPRS Number-.. ' Business Phone Number <br /> (uoba�s Address(Street,City, to Zip Code) as l �j 1 Z - (j fs<6. S g I, D I b3 <br /> �1( (+`I (�wNi lc �cvv�,c,Icee , 53S.97 <br /> VIIL Cann tylDepartmeot Use Only <br /> Cpproved ❑Disopivaved _Permit Fee Data issued Issxilrig• t;� <br /> ❑Owner Given Reason for Denial 5 71 — 3 26 —20(7 <br /> IX.Conditions of Approval/Reasons for DlsnpproVOl <br /> sk RECEIVED <br /> MAR 2 8 2017 <br /> Attach In rnmplcte plans fur Hip rpslen ant submit In Ike County nnlyan paper not less than It to s ti Inches In she <br /> Public health MDC <br /> E rOnmental Health <br /> SBD-6398•(R.l I/11) <br /> SCANNED <br />