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° <br /> ';i County J <br /> • a z Industry Services Division DANE <br /> 1400 E.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 1".-'71' Madison,WI 53707-7162 <br /> / 3'e,1-(,)7 - oofO I -" <br /> Sanitary Permit Application State 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 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stets. <br /> 1 I. Application Information—Please Print All Information MALONE ROAD <br /> Property Owner's Name Parcel# 0(2O1 " J013- J31)- 9�.'' <br /> RAMI ABUROMIA&RACHEL MOLANDER 06078159-0 <br /> Property Owners Mailing Address Property Location <br /> 1993 STATE HIGHWAY 92 NE'/, SW '/, Section 29 <br /> City, State, Zip Code !Phone Number <br /> MOUNT HOREB,WI 53572 T 6 N,R 7 E <br /> •;I II.Type of Building(check all that apply) I Lot# 1 Subdivision Name <br /> I <br /> 1 i3�T or 2 Family Dwelling-Number of Bedrooms 1 Block# <br /> I <br /> C Public/Commercial-Describe Use CSM Number 0 City of <br /> 0 State Owned-Describe Use I 8287 0 Village of <br /> li'f ■ of SPRINGDALE <br /> III.Type of,mit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1!-lq System /0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. I <br /> 0 Permit Renewal 0 Permit Revision 1 0 Change of Plumber', 0 Permit Transfer to List Previous Permit Number and Date Issued <br /> I Before Expiration 1 1 I New Owner i <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> � <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground C At-Grade 0 Mound>24 in.of suitable soil ta'iC4ound 5 24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gad) i Design Soil Application Rate(gpdsf) Dispersal Area Required(sq �1..Dispersal Area Proposed(sf) System Elevation <br /> 600 0.4 i 1500 1680 109.35' <br /> I VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units '1 <br /> New Tanks I Existing Tanks '' U u 2 —_ <br /> Septic or Holding Tank 1250 / 1250 1 DALMARAY X <br /> i Dosing Chamber I 750 750 1 DALMARAY X ) i 1 <br /> VII.Responsibility Statement-I.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> I Plumber's Name(Print) `; u er's Signatu MP/MPRS Number I Business Phone Number <br /> ISCOTTLOVELACE 226-852 I (608)465-3314 <br /> Plumber's Address(Street,City,State, tp Code) <br /> LOVELACE PUMP COMPANY,INC.,9914 COUNTY M.ARGYLE,WI 53504 "^ <br /> VIII. ounty/Department Use Only ,.-'� �� <br /> Approved! 0 Disapproved Permit Fee Date I pert. �j I�ssU;n ...^� •g n�fare `( ``� <br /> 0 Owner Given Reason for Denial S 11'00 y/t/i / /=�� <br /> IIX ditions of Approval/Reasons for Disapproval M� <br /> TdCT /!vq/ S'1 4Wi 4Z4 IS Pee Paa.wssei /N /rf .�Gf7�vte r <br /> 16owoirls90. AA" P'S1?itBf$ , rW4"r7v, ew,.��,a►.r,, --v .rllr .. _.. QtO, <br /> !-," T? J4' 4-_ . t le ter OFF .,T cCee r <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x I I inches i <br /> SBD 6398(R 08/14) SCANNED <br /> Public Health MDC <br /> Environmental Health <br />