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••1...eri°4 <br /> 'a�;. , Safety and Buildings Division County Dane `J"�'� <br /> ;11E44*it 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,ir(iii • Madison,WI 53707-7162 <br /> �� - 4.0 %7 ---0 a/r"f <br /> Sanitary Permit Application State TransaetfonNwnber <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. Nolet Application forms for slate-owned POWTS.are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Scrvits. Personal Information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.0+1(I Xt ),Slats. <br /> I. Application Information-Please Print All Information Cross Country Road <br /> Property Owner's Name Parcel e <br /> William & Kim McGilvray / 0608-142-8531-3 / <br /> Property Owner's Mailing Address Property Location <br /> 230 Ridge View Trail Govt Lot <br /> City,Slate - Zip Code Phone'Number NW tc, NW% section 14 <br /> Verona, WI 53593 220-8001 T 6 N, R 8 (circle one) <br /> 11.Type of Building(check all that apply) Lot H <br /> ®I or 2 Family Dwel ling-Number of Bedrooms 4 , 1 Subdivision Name <br /> Block r; . <br /> ❑Public/Commercial-Describe Use ❑City or <br /> ❑Stine Owned-Describe Use <br /> CS Number ❑Village of <br /> 5263 ®Town of Verona <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. re System./ <br /> ❑Replacement System ❑Treatment/Holding lank Replacement Only <br /> ❑Other tviodificatfon to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check ail that apply) <br /> 8 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Monttl>24 hi.ofsuitable soil ❑Mound<24 in.of suitable soil. <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DlspersalfTrcatmcntArea Informntion: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 600 / 0.6 _ 1000_ / 1008 98.2', 98.7' <br /> VI.Tank Info Cnpecftyin Total H of Manufacturer <br /> Gallons' Gallons Units ='• =Ja e O O <br /> New Tanks Existing Tanks ` o u <br /> aU isi 01 -1A P. <br /> Septic or Holding Tnak 1000/300 1300. 1 Dalmaray x <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibWty for installation of the POTS shown on the attached plant. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> `Titwf\r,•.� S,e.lt� .,/. as �5a5 Co$-ej5 t7l4bb <br /> Plumber's Address(Street,City,State,Zip Code) o <br /> • /3 o Fr i4x_ P . Ve -otoc , wz 53593 <br /> VII ounty/Dcpartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issui ;_ nTS' •.: <br /> ❑owner Given Reason for Denial 6///17 #0er_copli..-6 IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> foie.;) i C V \t-q:I,,,, {a�gry`q,;t* to- as, t (I MAY 2 5 2017 <br /> `,, Alta la complete for the stem and submit to the County only on paper eat les Ifs s I l Indus In size <br /> //��'t1et(' adv-'BOD j Public Heg tMDC <br /> t✓a4gv /.tut p - d — f" 44(-0. 9' 9 * ._uJ SN /17 <br /> Env�irort:ri .( Heart <br /> SBD-6398(R.l I/1 I) <br /> SCANNED <br />