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ti <br /> :`:i�•rx_rtri;t5„ County n <br /> • Industry Services Division Dane 1 <br /> NNEp 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 3 1=1 P.O.Box 7162 <br /> t S Madison,WI 53707-7162 <br /> -.‘.4i,.--.:k-- — <br /> Sanitary Permit Application State Transaction Number QQ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ( 3 -aj o I 1 - O O'8p <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> _ purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stets. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Matt&Megan Iverson c R z cla�S 1"- <br /> (i p51( - 4-.)- Elf3J0 - O <br /> Property Owner's Mailing Address Property Location <br /> 2263 Hammond Road <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE'/,SW'/, Section 22 <br /> Stoughton,WI 53589 (circle one) <br /> T5N ; R119orW <br /> H.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# giditAI 3 CSnj ' 912927 <br /> ❑ City of <br /> 0 State Owned—Describe Use Village of <br /> fiber (�Town of J94 fjj( Lk,i)A 'k <br /> III.Type ermit: (Check only one box on line A. Complete plicable) <br /> A New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (C ck all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Groun ® 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 Dis sal Area Required(sf) Dis sal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 7 J''S� 97.30 <br /> VI.Tank Info Capacity in <br /> as a .o <br /> Gallons Total #of Manufacturer a t" V <br /> Gallons Units v c t 8 .n 3 4 <br /> Nov Tanks Existing Tanks 4t V in ,,, y i, p,• <br /> Septic or Holding Tank 1 1029 I Dalmaray ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 763 763 1 Dalmaray ® ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S' ture MP/MPRS Number Business Phone Number <br /> Sean Crull / 251657 608-289-0593 <br /> Plumber's Address(Street,City,State,Zip Code) L <br /> 7030 Tolles Rd,Evansville WI 53536 ( k.$01 S l-I' ton . n"-' <br /> VIII.County/Department Use Only <br /> ‘Viproved ❑ Disapproved Permit Flee Date s'-d Issui 01 Agent . . <br /> -Approved <br /> 0 Owner Given Reason for Denial $ /� `r --J�--, ' ,`:; slwlud:� <br /> IX.Conditions of Agp{o, vaUReslsgns for Disappr� Q. .�a <br /> - ,�j, . ji'..�►-'' 4.3 .,v-ii vtT>< `'L C ' 7 MAR 1 4 2017 <br /> Public h 'alth MDC <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 r f'a'irnenta"I Hc3lth <br /> SBD-6398(R03/14) <br />