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,e, + 14:y,.\ County <br /> ljfl .. .• Safety and Buildings Division Dane <br /> r$r"0S ,-''R' ,�, - D(W.Washington Ave.,P.O.Box 7162 Sanitary Permit Nwnber(to be Ned in by Co.) <br /> 't� P8 Madison,WI 53707-7162 <br /> i '.,.•, i <br /> � , 13-- 2,oi10 - nc�z>°0 <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pennil. Nola Application fauns for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Savers. Personal information you provide may be used for secondary <br /> I. Application accordance <br /> nfo with the <br /> -Plea Please Print tAlllfor Sorts. w✓1ETi /E <br /> I. Application lnfonuatioa-Please Print AU Information C 1 `iF{ Spring Valley Road <br /> Property Owner's Name Parcel# <br /> -''Aaron&Melissa Becker AUG 17 2016 ,,/ 0807-182-9501-0 <br /> Property Owner's Mailing Address Property Locution <br /> 6661 University Avenue, Suite 106 Public Health MCC Govt.l i <br /> City,Stale Zip Code ehwittiAalRigist Health ,;..-•SW re, NE S:,Section 18 <br /> Middleton,WI 53562 (circle one) <br /> 11.Type of Building(cheek all that apply) Lot# T 8 N; R 7 E or 1V <br /> ®I or 2 Family Dwelling-Number of Bedrooms 5 Subdivision Name <br /> Block# Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ID state Owned-Describe Use CSM Number ❑Village of <br /> [2i Town of Berry <br /> t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. r,.New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification Fcation to Existing System(ex p lain) <br /> r' <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dule Issued <br /> .Before Expiration Owner <br /> IV.Type of Powrs System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(c plain) <br /> V.DispersaliTreatnrcnt Area lnformntlon: <br /> Design Flow(god) Design Soil Applicf4lton Rate(gpds1) Dispersal Area!Impaired(st) Dispersal Area Proposed(s() System Elevation <br /> 750 .1:'0 , :.: 7. %f„''':a(7- X62• . . _ 96.5' <br /> VI.Tank Info . a Capacity in "Total #of Manutheturer <br /> Gallons Gallons Units o o-E 2 <br /> Vg;u <br /> Mn w Tanks Enjoin Tanks a 1 11 t <br /> L U iii w en C t7 G. <br /> Septic cc Helaine rank 1000/600 1600 1 Crest x <br /> Dosing Chamber 800 800 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' •ignature MP/MPRS Number Business Phone Number <br /> 7-frit.LitS Vic -,-LV Z 4-l`-1-4, ''a 7-Acy <br /> Plumber's Address(Street,Ciiy,$01 Code) O IQ/4i4 4 I b y <br /> VIII.County/Department Use Only <br /> ❑Approved ❑Disapproved Permit Fee Date Issued Issuing A <br /> S / <br /> ❑Owner Given Reason for Denial 9 q/ /4 li,..- -;rif,1 <br /> IX.Conditions of Approval/Reasons for Disnpprovol <br /> !!! <br /> ` ger*cT NOVap l're T N /tS /Yet9r/kl6 Ler*Dilicer. Al. D4174,0,yrrcd- <br /> /0 of 4'fr/#'.v, .46 test out nv ow oil 4hezo.. t► -12jgtis!. <br /> Attach to complete plans f o r the s.stem and submit to the Counts only no paper not less than 11 ins I I inches In size <br /> SBD-6398(R.11/11) <br />