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,4,iicrxrif fv.s County QYJ` 1 <br /> ,' � ,: Industry Services Division Dane /` <br /> Si. p 1400 E Washington Ave <br /> Sp • I-1 Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 3 P.O.Madison,WI 53707-7162 <br /> ! i 3 301'1- do l°i 3 <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 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Safety and Professional Services. Personal information you provide may be <br /> used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Lot 1 <br /> I. Application Information-Please Print All Information R t€9 e, Ln <br /> Property Owner's Name Parcel# <br /> Dennis R&Jacquelyn J Ribble 024/0712-231-9710-0 <br /> Property Owner's Mailing Address Property Location <br /> 5600 Lexington St#5 <br /> Govt.Lot <br /> City,State I Zip Code I Phone Number SE I4,NE IA, Section 23 <br /> McFarland,WI 53558 608-65R-ow circle one) <br /> —__— I ,_ -. ._ ', 07 ; R 12 E or W <br /> II.Type of Building(check all that apply) Lot# <br /> O 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block(/ <br /> ❑ City of <br /> ❑State Owned-Describe Use ❑ Village of <br /> CSM Number <br /> ® Town of Deerfield <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. El New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit ❑ Permit Revision ❑Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration - <br /> IV. Type of POWTS System/Component/Device: (Check all 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 ROther Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> F-04.4 R 3' if. Si O 4.( t< . u44010' A CELGI <br /> V.DispersaUTreatment Area Information: - <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) 5 .,,_ P l 0 4 P 1 o..Y1 <br /> VI.Tank Info Capacity in a <br /> Gallons , d i (), <br /> Gallons Units Manufacturer U s .g .8 C7 a, <br /> New Tanks Existing Tanks <br /> Septic of-Het/Mg Tank (C j C, ''35o l 000 I Y■A e Pt.Cie &] ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ - ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> P m is Signature, MP/MPRS Number Business Phone Number <br /> ,S-I'eve.n 1.77e-S m�f <'� T -k -v (4/rvv._4 <br /> Z-'2_--1 i I le z...0 7?-2:37c1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N4 .S C�vn+l.l RA. 0, 1, ai—e1-10o, "I1 S-3559 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent igna re <br /> ❑ Owner Given Reason for $ y Q 1 6-2ff-ZOO? G��N�� � "1 C ( A <br /> Denial _ <br /> RECEIVED <br /> SCANNED JUN 2 7 2017 <br /> SBD-6398(R03/14) Public Health MDC <br /> Environmental Health <br />