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/ v3 County 1//�/ <br /> / tsau a4� Safety and Buildings Division Dane IV7 <br /> !4'r�8.�,°^'•It�r 201 W.Washington Ave.,P.O.Box 7162 snowy panne Number po be piled to by Co.) <br /> L$P23i Madison,WI 53707-7162 <br /> i1-44 17- 0oo9S- <br /> Sanitary Permit Application State TrwoaetierlNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this(boats the appropriate govermtlentelunit <br /> is required prier to obtaining a mmbary permit.Nate Application forms for slate-wined POINTS are submitted to Project Address(Valorem than mailing address) <br /> the Department of Safety and Professional Scn'ies. Personal information you provide may be used for secondary <br /> pwpoxs in accordance with the.Privacy Law,a.15.04(1 Xml,Slats. Lunde Circle <br /> 1.Application infarm:Ilon-Please Print All Information <br /> Property Owner's Nome Parcel 0 <br /> Brandon&Angela Nicholson 0611-331-5121-9 <br /> Property Owner's Mailing Address Property Location <br /> 812 Lincoln Avenue Govt.Lot <br /> City.State - p Phone Number SW td, NE /,section 33 <br /> Stoughton,WI 5 89 (ri' ono <br /> 11.Type of Building(check all that awl, Lot g T 6 N; R 11 Ear W <br /> IN I or 2 gamily Dwelling-Number of Bulroo 4 21 Subdivision Name <br /> Block Nordic Fields <br /> ❑Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑State Owned-Describe Usc CSMNamber ❑Village of <br /> ®Town of Pleasant Springs <br /> III.Type of Permit (Check only one has on line A.Complete line B If applicable) <br /> A' N New System ❑Replacement System ❑TreelmenNiolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revidon ❑Change of Plumber ❑Pena Transfer to New List Permit Number and Ditty Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Devicw (Check a6 that apply) <br /> ®Non-Pressurised in-Ground ❑Preswrtred lo-Ground ❑At-Grade ❑Monad:24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Neumann Device(explain) <br /> V.DtspersalfrreatmentArea Information: <br /> Design Flow rand) Design Soil Application Rme(gpdsl) Dispersal Area Rega n:I(sl) Dispersal Area Proposed(s) System Elevation <br /> 600 0.7 858 900 92.5',93.0' <br /> VI.Tank Info Capacity in Total if of Mtmufo-terse <br /> Getlans Gallons Units ` <br /> � <br /> New Tanks Fsiaies Tanks g 11 i <br /> is.U 'oor V3 e o a <br /> Se"'"'.No*1asTook 1250 — 1250 1 , Crest x <br /> Dosing chwber 750 750 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,on me responsibility for Instagatioe of the POWrS shown on the attacked plans. <br /> Plumber's Name(Print) P Signature MMMPItS Number Business Phone Number <br /> --rm,,,S Srte.4 ,� --,C /00,2402.z tlz.Y-gory <br /> Plumber's Adelas(Street,City.Stnte,Zrp Code) <br /> 78'b9 Cie( 4/ D llrc"/z- 3 O g <br /> VIII.County/Department Use Only <br /> �Appraved ❑Disapproved Pemdl Fee Date Issued Issuing t Si <br /> ❑Owner Given Reason for Denial S t —1 -2D1/ /���'/Mr- <br /> IX.Conditions of Approvel/Reesons for Disapproval <br /> CANNED RECEIVE <br /> APR 12 2017 <br /> Attach le omaptele pions for the system red sahmit to the Ca a n r ne a In dm <br /> Public Health MDC <br /> Environmental)- aith <br /> SBD-6398(R.11/I I) <br />