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• <br /> ''•' ►i County <br /> 41--f;'1,.,,... � Safety and Buildings Division Dane .�"^ <br /> ' h:;,t.14y i 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Cm)P,S; i'4! Madison,WI 53707-7162 <br /> � - '' I3_ aor7— Oo(IS� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2).Wis.Mm.Code,submission of this Corm 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 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(1)(m).Slats. <br /> I. Applicadonlnfartuation-Pleuse Print All Information Sunset Drive <br /> Pro vner's Name Parcel# <br /> Daniel&Kaye McGrath 0608-353-8055-0 <br /> Property Owner's Mailing Address Property Location <br /> 426 Kelly Street Govt,.Lot t� <br /> City,State Zip Code Phone Number r/�JE IA, SW %, Section 35 <br /> Sun Prairie, WI .-44..... (circle one) <br /> 11.Type of Building(check nil that np Lot# T. 6 N' R 8 E or W <br /> IN I or 2 Family Dwelling-Number of Bed its 4 3 Subdivision Name <br /> Block# . <br /> ❑Public/Commercial-Describe Use ❑City or • <br /> III State Owned-Describe Use CSM Number ❑Village of <br /> 1--------13919 l Town of Verona <br /> III.Type of Penult (Check only one hex on line A. Complete line B if applicable) <br /> A:viliiNeiv System y ❑Replacement System ❑Treatmentll•Iohiing'[Lnk Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check nil 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 lam-motion: <br /> Design Flow(gpd) Design Soil Application Rate(gpds1) Dispersal Area Required(si) Dispersal ArenPro osed(si) System Elevation <br /> 600 t.:•."0.6 _ -1-00000 93.0' <br /> VI.Tank Into Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u <br /> New Tanks Existing Tanks <br /> u „ <br /> el 3 err-u in t o o. <br /> Septic or Holding Tank 44250 1250. 1 Crest <br /> Dosing Chamber X <br /> ,7,31i 750 1 _ Crest x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum s Signe MP/MPRS Number <br /> liminess P <br /> ho N <br /> 2t vo .Y-J jOb-2 2r /i� <br /> Plumber's Address(Street,City,Stae,Zip C d) M <br /> 7gOq C-trr <br /> < <br /> U 12&/(141--e,'7/6 ("c.1 4111r 411 _ rs .. <br /> VuI.County/Department use Only ' <br /> r <br /> li <br /> Permit Fee Dale Issued . - ssuin r <br /> Approved ❑Disapproved S g •_ent5i .• :.�� <br /> Y <br /> ❑Owner Given Reason for Denial tt4L i � ,""*��►. <br /> IX.Conditions of Approval/Reasons for Disapproval . <br /> Alined to complete plans for the system and submit to the County wily an paper not less than A 112 a 11 Indies In size <br /> 5BD-6398(1Z 11/11) . w _ - i E D <br /> SCANNED <br /> MAY 0A 2017 <br /> • <br /> f`Abiic health NDC <br />