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County / n,.;.� Safety and Buildings Division Dane rN\ ,R1,;.tri•r1rt 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled In by Co.) 'a1 `°li . rl Madison,WI 53707-7162 i��t ��v'S: � �. 13-ezor7- 00107 Sanitary Permit Application State T'anssetio,tNumber lo accordance with SPS 383.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental unit is required.prior to obtaining a Rainy permit. Note:Application forms for st ate-owned POWI'Sare submitted to Project Address(if difiercm than.mailing address) the Department of Safety and Professional Scrvies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)<m),Slats. Colby Road 1. Application Intormaflon—Please Print All information Pntpeny 'er's Name c.— rad Beghin 0507-042-8590-7 Property.Owner's Mailing Address Property Location 701 Hildreth Road City,'State Zip Code Phase Number G b, NW'l4,Section 4 Stoughton,WI 3589 514-3685 T 5 N R 7 (circle one) H.Type of Building(cheek all that a ly) Cote Iil I or2 Family Dwelling-Number of 4 Subdivision Name Block# . ❑Public/Commercial-Describe Use ❑City of • ❑State Owned-Describe Use CSM Number , ❑Village of 158 ®Town or Primrose III.Type of 1t: (Check only one bar on Him A. Complete line B If applicable) t New System ❑Replacement System ❑Treatmenl/Hoid lug Tank Replacement Only Q Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Penal Transfer to New List Previous Permit Number and Date Issues! Before Expiration Owner IV.Type of PONVI S System/Component1Deviee: (Check all that apply ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-Ciro Mound>24 is or suitable soil ❑Mound<2.4 in.of suitable soil ❑holding Tank ❑Other Dispersal Component(espiain) 0 Pretreatment Device(explain) V.Dispersal/Treatment Area Information: Design Flow(god) Design Soil Appticaj$oit Rate(gpdsl) Dispersal Area nkari(at) Dispersal Area {s1) System Elevation 600 e).(Ce 6 ier,e _ I5)91 5 102.0' VI.Tank Info ! Capacity in al II of Menu acmrer Gallons Gallons Units s is$ o New Tanks Existing Tanks g 3.1 1 11 g o.0 in .n E i=,0 F. Septic or Holding Tank 1250 1250 1 Crest X Dosing Chaska 750 _ 750 1 Crest _ x _ VII.Responsibility Statement-1,the undersigned,assume _jroasibtllty for Installation al the POWTS shown on the attached plans. PI 's Name(Print) Plumber's 5 turn MP/MP . • = - Phone Number Clot-4- 4wQ t 1/7z 7 0.7 Plumber's Address(Street,City.State.Zip Code) Plea Oa f Df �.1ti0 L 71 fit ‘it I s- �"py V111.Corm /De.artmedt Use Ord / ter/ Permit Fee Date ri_' . :�. pproved Disapproved s R i b/ �S ❑Owner Given Reason for Denial t ' ' `j, , _-_ IX.Conditions of Approval/Reasons for Disapproval DAttach to complete plans for the system and submit to the County only at.. . eat less than 8 la a II lechers i4 E C ETV APR 2 4 2017 SBD-6398(R.11/)1) • Public Health MDC &;,y Environmental Health d ,s;