Laserfiche WebLink
.4� I County 1 <br /> i' t e .y t Industry Services Division DANE 12,4 <br /> s :: 1 <br /> r. ` 1400 E.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '\ r--. %s Madison,WI 53707-7162 <br /> -_—:= i3- 40/)— 00/68 <br /> Sanitary Permit Application State Transaction Number <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.Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies.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 Xm),Scats. <br /> I. Application Information-Please Print All Information MULLER ROAD <br /> Property uet is Name Parcel P <br /> WILLIAM&DAWN PORTER 0911-181-8250-0 <br /> Property Owner's Mailing Address Property Location <br /> 7382 NORWAY ROAD t..---"NE '/., NE ''/., Section 12 <br /> City, State, Zip Code Phone Number <br /> DEFOREST,WI 53532 608 576-7324 T 9 N,R 11 E <br /> II.Type of Building(check all that apply) - Lot P ✓ 2 Subdivision Name <br /> @'i or 2 Family Dwelling-Number of Bedrooms ('-- 4 Block 8 <br /> ❑Public/Commercial-Describe Use CSM Number 0 City of <br /> D State Owned-Describe Use 4419 0 Village of <br /> C4-1‹,in of BRISTOL <br /> III.Type of�P rmit: (Check only one box on line A. Complete line B if applicable) <br /> A. t➢'1`1ew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision I 0 Change of Plumber 0 Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil QMound 5 24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design low(gpd) Design Soil Application Rate(gpdsf) Dispersal Arc Required(sf) Dispersal Area Proposyd(sf) System Elevation <br /> 600 C.6 L.V.- <br /> . 1000 _ _ 350 102.95' <br /> VI.Tank Info Capacity in Total fl of Manufacturer <br /> Gallons Gallons Units u `o -m <br /> New Tanks Existing Tanks e B U y y <br /> S 8 .8 a <br /> , a U 'en- B rn iu- C7 a • <br /> Septic or-Balding Tank 1250 — 1250 1 CREST X <br /> Dosing Chamber 750 750 1 CREST x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu tier's Si re MP/MPRS Number Business Phone Number <br /> JOHN E.RASMUSSEN ��¢ 223-732 (608)635-4305 <br /> Plumber's Address(Street,City,State,Z' Code) <br /> ARLINGTON HARDWARE CO.,INC.,P.O.BOX 169,ARLINGTON,WI 53911 <br /> VIII.County/Department Use Only <br /> proved 1 I <br /> 0 Disapproved Permit Fee Date Issued Issu' g A Si ture <br /> I <br /> 0 Owner Given Reason for Denial $ 14-46 646-20/7 C j"-- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Q�9 !� <br /> DaAiv(ft- ,11( (1 g47hRAt c'svi ll;r4 ��r*" <br /> RECEIVED <br /> S-f`C Zyr f°e 6-y-c4 Oik r i=1,0 rwcuAit ( --,,, Cr <br /> Attach to complete plans for the system and}y¢ Ite Q_ ty only on paper less than 8 IR x I 1 inchesiUtke0- 2017 <br /> SBD-6398(R.08/14) S ANNE Public Health MDC <br /> Environmental Health <br />