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m��Fri County <br /> pii,. Safety and Buildings Division Dane w <br /> yt 0,4"t;,,s is r' 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be felled in by Co.) <br /> �,r!!' Madison,WI 53707-7162 <br /> 'z' (7.40/)--- DtIf <br /> �+�Slr.^K+i°'i <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with SPS 383.2l(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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Scrries. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(mi.Scats. <br /> I. Application Inforntntion-Please Print All Information <br /> Property Owner's Name Parcel <br /> David &Aileen Hruby 0907-354-8000-5 <br /> Property Owner's Mailing Address Property Locution <br /> 6531 Matz Road <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE 14, SE '''A, Section 35 <br /> Dane, WI 53529 (circle one) <br /> T 9 N; It 7 E or W <br /> 11.Type of Building(check n11 that apply) Lot 4 <br /> ®I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Blocky 40 Acre Farm Parcel <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of Roxbury <br /> III.Type of Permit: (Check only one box on Fine A. Complete line B If applicable) <br /> ❑New System 0 Replacement System ❑Treatmentlhlolding Tank Replacement Only ®Other Modification to Existing System(explain) <br /> Reconnect to existing system <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Dote Issued <br /> Before Expiration Owner <br /> IV.Type of rovers System/Component/Device: (Check nll 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 ❑Other Dispersal Component(exptoin) ❑Pretreatment Device(explain) <br /> V.DispersaUTrcatment Area Information: <br /> Design Flow(gild) Design Soil Application Rate(gpdsl) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.5 900 900 90.09', 99.97' <br /> VI.Tank Info Capacity in Tote) 4 of Manufacturer <br /> Gallons Gallons Units .n ` o• <br /> E <br /> New Tanks Existing Tanks '11' 2 3 � g <br /> o <br /> 42 U rn rn i.O a. <br /> Septic or}Iolding Troik ' 1000 1000 1 Wieser X <br /> bating Chamber 600 600 1 Wieser x <br /> VII.Responsibility Statement-I,the undersigned,assume respo ibllity for lnstallatinu oldie POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si I r MP/MFRS Number business Phone Number <br /> Char(PPe.- t -J t9av/a9/ (,OS-&43- 863/ <br /> Plumbers Address(Street,City,State,Zip Code) <br /> VOG7i JIAA 4d0-4/75 Sf ,ioz elEte 5'?u,_ 6I-, livl 5358 3 <br /> VIlL C unty/Department Use Only ,( <br /> fie- <br /> Approved ❑Disapproved <br /> Perm�iyt F"." Date Issued !swirl turn /I <br /> ❑Owner Given Reason for Denial 1071) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach In complete plans for the system pout submit to the County only no paper not less than fl tin s 11 Inches In stR E C ENE D <br /> sBD-6398(R.1 in i) - JUL 0 6 2017 <br /> mow-- Public Health MDC <br /> ""°_�' Environmental Health <br />