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{� ur!Qvi County —VIA_ <br /> r <br /> 4%.f.,11“. \ Safety and Buildings Division Dane <br /> $t l .'i I. N 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \- g, r1 Madison,WI 53707-7162 <br /> ;.,i � t 3-den) c.o./3 b <br /> v +�y <br /> Sanitary Permit Application State Transaction Number <br /> to accordance with SPS 383.21(2),Wis.Mm.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 Project Address(if different Man 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(I)(m).Slats. Spring Rose Road <br /> I. Application Infornuttion-Please Print All information <br /> Property Owner's Name Parcel# <br /> Matt Klein 0607-254-8260-0 <br /> Property Owner's Mailing Address Property Location. <br /> 6635 Franklin Avenue Govt.Lot <br /> City,State Zip Code Phone Number NE IA SE y, Section 25 <br /> Middleton,WI X356 235-0390 T. 6 N; R 7 {circle one) <br /> 11.Type of Building(check nil that apply''r✓ , Lot 0 <br /> $.i I or 2 Family Dwelling-Number of Bedrooms 5 1 Subdivision Name <br /> Block it . <br /> Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑Stole Owned-Describe Usc CSM Number ❑Village of <br /> 12812 M Toirn of Springdale <br /> iII.Type of Permit: (Check only one hay on line A. Complete line B If applicable) <br /> '\ RI New System ❑Replacement System ❑Treatmenl/Holding Mink Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check nil that apply) <br /> o Non-Pressurized la-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(gpdsi) Dispersal Area Required(si) Dispersal Area Proposed(si) System Elevation <br /> 750 1.0 /0,(0 750 ((2 So 750/(5 100.4' <br /> VI.Tank Info Capecity.in Total of Manufacture <br /> Gallons Gallons Units a E o a <br /> New Tanks Existing Tanks `".. e a u 1` . i3 <br /> atJ yb'K rn i=o Cr.. <br /> Septic or 4el agTank 1000/600 —' 1600 1 Dalmaray x <br /> Dosing Chamber 750 f 750 1 Dalmaray x <br /> Vit.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. . <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> — .ZMok"y S "Se lte I e =y th¢ _ =7_50 5 bog -SYs-7“6 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 133 0 F.-► Rd . V - �1 i w 51513 <br /> V111.County/Department Use Only --°„. <br /> Permit Fee Dare Issued lts'ui gc Si ore (pproved ❑Disapproved cr l �C l�[teason for Denial � -� � <br /> IX Conditions of Approval/Reasons for Disapproval <br /> PRA7 ectr Wt•ctNYO ftf:' . r( - ,o s/Q is"Fl<E-T %o/ /� /T1 <br /> N/-r.4+ 0./ye P :crE-c.7 FAA— t—e —4--c---(4169- Cca- E-CMN/ff17rp <br /> R+,(o V E&jial[,AX 1ri� ci <br /> Attach to complete plans for the system and submit to the County anty on paper oat leas thnn 8 IQs I I inches In size <br /> RECEIVED <br /> SBD-6398(R.lI/I I) SCANNED <br /> MAY 18 2011 <br /> Public Health t4DC <br /> Environmental,Hea,Ith <br />