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County
<br /> s\t'N Safety and Buildings Division Dane
<br /> Ai 1...:1:4;•.-;',',,),,IV; 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)
<br /> ,o -;•;.,S-t- -;:t"l. F.,
<br /> '1,1 :.,....,sfl ,' Madison,WI 53707-7162
<br /> Jitfrt
<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 1 3-do1 -7 — 60 ( b 3
<br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS ore submitted to Project Address(if different than mailing address)
<br /> the Department of Safety and Professional Scrvies. Personal information you provide may be used for secondary
<br /> purposes in accordance with the Privacy Law,s.l5.04(1)(m),Sluts. Malone Road
<br /> 1. Application Information-Please Print All Information
<br /> ProncryOwner's Name Parcel y„.„-
<br /> '
<br /> ---"-.Marty &Alicia Szekeres .,..-..------ 0606-251-8325-0
<br /> Property Owner's Mailing Address Property Locution
<br /> 116 Robyn Ridge
<br /> Goy).Lot ----"
<br /> City,Stale Zip Code Phone Number 6"-SE ;4, NE IA, section 25
<br /> Mt. Horeb, WI 53572 577-7515 (circle one)
<br /> T 6 N; R 6 E or W
<br /> II.Type of Building(check all that apply) ,„ Lot#
<br /> Name e----
<br /> tgi I or 2 Family Dwelling-Number of Bedrooms 3 (---1 Subdivision
<br /> Block 4'
<br /> 0 Public/Commercial-Describe Use
<br /> 0 City or •
<br /> 0 State Owned-Describe Use CSM Number 0 Village of
<br /> 4----14415 li0 Town of Blue Mounds
<br /> III.Type of Permit: (Cheek only one box on line A. Complete line B If applicable)
<br /> Z121New System
<br /> 0 Replacement System 0 Treatment/liolding Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> B. El Permit Renewal 0 Permit Revision 0 Change of Plumber El Permit Transfer to New
<br /> Before Expiration Owner
<br /> IV.Type of POWTS System/Component/Device: (Check all that apply)
<br /> 0 Non-Pressurized in-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in.of suitable soil 0 Mound<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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so) Dispersal Area Proposed(sf) System Elevation
<br /> L..-4-50 ..-----0.6 Z---750 ---/50 110.2'
<br /> VI.Tank Info Capacity in Total #or Manufacturer
<br /> v. ...,
<br /> Gallons Gallons Units .0 P. ,,'
<br /> New Tanks Existing Tanks il' ,S' Ts,:45 T .g:6 1
<br /> a.-u in ,,, in- IL'r.., F.
<br /> Septic or itolding Tank --t600 1000 1 Crest x
<br /> Dosing Chamber
<br /> ,,,,600 600 1 Crest x
<br /> Vii.Responsibility Stittement-I,tire undersigned,assume responsibility for Installation of the POWTS shown on the attached plans.
<br /> PlumIKINLIae(Print) Plum s Signature NIP/MPRS Number Business Phone Number
<br /> Plumber's Address(Street,City,Slate,Zip Code)
<br /> A-i7S(6+1 C%?-'1 ,7.-d 0 $2tlei4/(e (Ail:- s , 0$
<br /> VIII.County/Department Use Only
<br /> Permit Fee Dale Issued lssui •:cat Si:,• • '111111116'"'"..4
<br /> t Approved 0 Disapproved .41k......
<br /> 0 Owner Given Reason for Denial 5 4 .-L( (9 4/,24, -! „ ,,,...„
<br /> IX.Conditions of Approval/Reasons for Disapproval
<br /> RCEIVED
<br /> APR 1 9 7n17
<br /> Attach In complete plans for the system and submit to the County only on paper not less than ft IC 1 II Inches In size
<br /> Public Health MDC
<br /> Environmental Health
<br /> SBD-6398(R.I i/I1)
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