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<'4.4A ;it-i County <br /> 4}',11)11:,,-.. N.". Safety and Buildings Division Dane <br /> ;r' ;: ttilyiL,I 201 W.Washington Ave P.O.Box 7162 <br /> ,r, :::04_• FI 9 Sanitary Permit Number(to be filled in Co.) <br /> Madison,WI 53707-7162 <br /> i' �' s` /3 — 2 �� c9/3 <br /> .y <br /> -C9 d <br /> Sanitary Permit Application State Immerged;Number <br /> In accordance with SPS 383.21(2),Wis.Mm.Code,submission ofthis form to the appropriate govennnentai unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWVIS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Scrvies. Personal information you provide may be used for secondary <br /> purpose in accordance with the Privacy Law,s.15.01(1}(m),Slats. . Blue Mounds Road <br /> I. Application Information-Please Print An Information <br /> Property Owner's Name Parcel# <br /> Travis Helen ✓ 0606-204-8515-2 <br /> Property Owner's Mailing Address Property location <br /> 604 Vicki Lane Govt.Lot <br /> City,Stale Zip Code Phone Number NW IA, SE G, Section 20 <br /> Mt. Horeb,WI <` 6 (circle one) <br /> IL Type of Building(check all that apply) Lot# T N; R 6 E or 1y <br /> N I or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> Block# 13.22 Acre Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use ❑city of • .... <br /> ❑Slate Owned-Describe Use CSM Number ❑Village of <br /> N Town or Blue Mounds <br /> (If.Type of Permit: (Check only one box on Hite A. Complete Bacilli-applicable) <br /> A ®New System ❑Replacement System ❑Treatment/Holding/rink Replacement Only ❑Other Modification 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/Deviee: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground al Al-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 In.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s0 Dispersal Area Proposed(si) System Elevation <br /> 600 0.6 1000 ' 1000 100.0' <br /> VI.Tank Info Capacity.in Total it of Manufacturer <br /> Gallons }s Gallons Units a u° g .3 <br /> New Tanks Existing Tanks ii g 1 A d ;8 <br /> 0.0 Fs n to iZ CI G. <br /> Septic or Holding Tank 1250 / 1250 1 Dalmaray x <br /> Dosing Chamber 750 ." 750 _ 1 Dalmaray x _ <br /> VII.Responsibility Statement-t,the undersigned,assume responsibility for tallation of the POWNTS shown on the attached plans. <br /> Plwtls <br /> er's Name(Print) P Signature NIP/MFRS Number Business Phone Number <br /> „„,,,e _Plumber's Address(Street,City,Stale,Zip Code <br /> °1914 i-1, m c i�, w s35DY <br /> rd <br /> Vil aunty/Departre <br /> Use Only <br /> Approved ❑Disapproved $Permit Fee Data Issued Issuer are <br /> �/ <br /> ❑Owner Given Reason for Denial 1 47)-46 DS 77// l�, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pie*fel ( i —off nr(z, A ,o M /.S Por'✓rl/o,.0E AA( /Tr <br /> NAT t Chic(4wi. ego74--c-? 6Ph ,jv/L C., i - - - - - lAm�r/ <br /> A`''y Yt-ttlCU .r/ C-r <br /> Minch to complete plans f o r the system and submit to the County only on paper not less than Ala s I I Inches In size <br /> RECEIVED <br /> SBD-6398(R.11/I I) <br /> Atiee MAY 1 8 2017 <br /> Public Health MDC <br /> •---•...,.,r <br /> Environmental Health <br />