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)✓ <br /> Industry Services Division DANE <br /> a � P• I- 1400 E. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> f -` '• ' Madison, WI 53707-7162 <br /> I ,y - ..t c)/1— Asa co <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit 2q 1 eZ Or— <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(it'different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information RANKIN ROAD <br /> Property. ner's Name Parcel# <br /> ETER JOHNSON W-""0710-352-6914-3 <br /> Property Owner's Mailing Address Property Location <br /> 5236 DAY LILY PL. ,,,SE ''A, NW '/4, Section 35 <br /> City, State. Zip Code Phone Number <br /> FITCHBURG, WI 53711 T 7 N, R 10 E <br /> II.T yp e of Buildin g(check all that apply) j _ <br /> Lot# 1'44 Subdivision Name <br /> Eli og2FamilyDwelling-NumberofBedrooms <br /> 4 1 Block# -APRIL HILLS- 1ST ADDITION <br /> ❑ Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use ❑ Village of <br /> I EI4 vn of BLOOMING GROVE <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' a'Nef�w System ❑ Replacement System ❑ TreatmenUHoldine Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑ Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 2 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil Ck<ind_<24 in.of suitable soil <br /> 2 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain): <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.6 _ _1000 I 1139.78 102.3', 101.9' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a) <br /> New Tanks Existing Tanks z U " N <br /> v O :- V N . _r ti <br /> - a- U V7 v. V7 rL C7 C <br /> iepticgr—lplriingTank 1300 ...-- 1300 2 DALMARAY X <br /> )osingChamber I 750 750 1 DALMARAY X <br /> ✓I1. Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> 'lumber's Name(Print) Plumber's Sio Lure MP/MPRS Number Business Phone Number <br /> IIMOTHYJELLE Cci, 227-525 ' (608)845-7466 <br /> 'lumber's Address(Street,City,State,Zip Code) <br /> VERONA SEPTIC AND EXCAVATING, 1330 FRITZ ROAD, VERONA, WI 53593 <br /> all.County/Department Use Only _ w__--._.__..----- <br /> )Approved ❑ Disapproved Permit Fee Date Issued Issuing ntJ at re <br /> ❑Owner Given Reason for Denial $ 6t lJ+� 3 fS 20 '� �� s��� Alept_ <br /> X.Conditions of Approval/Reasons for Disapproval <br /> Iry!' -L f(77 D'fL,-,v 4%4e7/o er D pr _- <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in 1 3 2017 <br /> BD-6398(R.08/14) <br /> Public Health MDC <br /> SCANNEED Environmental Health <br />