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?t; 1 ;' ',i4 <br /> \ Industry Services Division DANE JAt. <br /> 1 1400 E.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \etro��t'�/ Madison, WI 53707-7162 <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.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information OLD OAK PASS <br /> Prope wner's Name Poet# <br /> MICHAEL& HILLARY WALTERS 1•'062/0608-052-2507-0 <br /> Property Owner's Mailing Address Property Location <br /> 2338 JEFFY TRAIL 4,,�NW V4, 414 'A, Section 5 <br /> City, State, Zip Code Phone Number <br /> MADISON, WI 53719 - ' T 6 N,R 8 E <br /> II.Type of Building(check all that apply) Lot# (✓��1 3 " Subdivision Name <br /> CD4r 2 Family Dwelling—Number of Bedrooms 4 Block# THE WOODS AT WATCH HILL-CONDO PLAT <br /> ❑Public/Commercial—Describe Use CSM Number ❑City of <br /> ❑State Owned—Describe Use ❑ Village of <br /> 1 fown of VERONA <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [9 fSystem ❑Replacement System ❑ Treatment/Holding 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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil I9'Mound 5 24 in.of suitable soil <br /> ❑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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 v' 0.6 v'' 1000 ``1537 99.2' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 9 .n <br /> New Tanks Existing Tanks v U :: v °— <br /> _ o U <br /> . iit H rn cZ v a: <br /> Septic or Holding Tank 1250 1250 1 DALMARAY X <br /> Dosing Chamber 750 750 1 DALMARAY X <br /> VII.Responsibility Statement-I,the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) umber's S' n a'i MP/MPRS Number Business Phone Number <br /> SCOTT LOVELACE 226-852 (608)46. 3314 <br /> Plumber's Address(Street,City,Sta , ip Code) <br /> LOVELACE PUMP COMPANY, INC., 9914 COUNTY M,ARGYLE, WI 53504 <br /> VIII.County/Department Use Only 4 <br /> proved ❑Disapproved Permit Fee Date Is ed Issuin€y�_ _-® <br /> 0 Owner Given Reason for Denial $ 4� a / �� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> SCANNED <br /> {DECEIVE® <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.08/14) APR 2 7 2017 <br /> Public Health MDC <br /> Environmental Health <br />