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/:ti irel fry' County <br /> /.0p1'4'.- Safety and Buildings,,Division Dane J 'L''� <br /> ,$r ,:p .R..i'�. 201 W.Washington Ave.,;P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,r: rS '' r1 Madison,WI 53707-7162 <br /> pi .i&r4St1 'j , <br /> � '; - <br /> � 3 an ii flop <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'sunitory permit. Note Application forms for stale-owned POW Ssre submitted to Project Address(if different Than mailing address) <br /> the Department of Safety and Professional Servies• Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law.s.15.04(18m),Slats. CTH F <br /> I.Application Infornuttion-Please Print All Information <br /> Property er's Name Parcel g <br /> ;" dam Kuen, olleen Condon 06-052-8150-0 <br /> Property Owner's Mailing Address Property Location <br /> 10686 Rowley Road <br /> Goof-�� <br /> City,State Zip Code Phone Number °"NE %, NW !G,Section 5 <br /> Blue Mounds,WI 3517\ (circle one) <br /> T. 6 N; it 6 E or W <br /> Ii.Type of Building(check all that apply) - Loth <br /> ®I or 2 Family Dwelling-Nwnber of Bedrooms 3 2 Subdivision Name <br /> ' <br /> � Block II . <br /> ❑Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑State Owned-DtscribeUsc CSMNu r ❑Village or <br /> 4.-------11179 ®To<"mor Blue Mounds <br /> Ill.Type of Permit: (Check only one her online A. Complete line B If applicable) <br /> Z„, System ❑Replacernent System 1 ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Nov List Previous Permit Number and Dale Issued <br /> Before Expiration 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 ❑Mound<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(gpdsl) Dispersal Area Required(st) Dispersal Area Proposes( 1) System Elevation <br /> 0 j-0" Ce 75e, ,46//. / 93.5' <br /> Vi.Tank info Capacity in Thai #of Ivi6ufacturer <br /> Gallons Gallons Units B o v <br /> New Tanks Existing Tanks i c ti a ` g . <br /> a.t..1 !n !d w y tL*o F. <br /> Septic or Holding Teak 1000 1000 1 Crest x <br /> Dosing chamber _ 600 600 1 _ Crest x <br /> ViI.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nome(Print) Pitt ignoture MP/MPRS Number Business Phone Number <br /> 7fCk 0 l5 C eSnfid- - l Zv '?- ... 412/4'1-3o 141 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> n178(o9 Cr t ltd 0 tae ieLf !lr w:-- s3508` / .�� <br /> V 11.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date ` Issue Agent • • �s <br /> 3 ��Fee ®I <br /> ❑Owner Given Reason for Denial ,erj.,..IX.Conditions of Approval/Reasons for Disapproval <br /> 'f <br /> Attach to complete pleas for the system and submit to the County only an paper not less than A us a II toots In size <br /> SBD-6398(R.II/ll) SCANNED tccCEIVED <br /> • <br /> MAY 03 2017 <br /> Public Health MDC <br /> Environmental Health <br />