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IIPPPI111.1111111111111.11.111111.*+,oviEro_i%.. County <br /> kr, 4+ Industry Services Division Dane§� 1400 E Washington Ave <br /> al S p ' 1 P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 'a S Madison,WI 53707-7162 <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 pcmnit. 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),Stats. Iaeh3 <br /> I. Application Information—Please Print All Information ex:A 0 I r' Cf. <br /> c, <br /> Property Owner's Name Parcel# <br /> Jesse&Annette Sullivan 024/0712-103-9055-4 <br /> Property Owner's Mailing Address Property Location <br /> 2060 River Estate Lane <br /> Govt.Lot <br /> City,State • , Zip Code Phone Number SW''4,SW'A, Section 10 <br /> / <br /> Stoughton,WI 9 (circle one) <br /> ff�� T007N R12EorW <br /> 11.Type of Building(check all that apply) Lot if <br /> ® I or 2 Family Dwelling—Number of Bedroom Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> 0-? u.<=I,.2.-- ® Town of Deerfield <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 18 New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> MI Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ Al-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 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> L-1 co Rate(gpdsf) L j 125 \1L\ (, 5,,_ P1 D-4- ( ,, v1 <br /> VI.Tank Info Capacity in <br /> 2 C <br /> Gallons P. t j` = <br /> Total #of Manufacturer a P. <br /> Gallons Units u c & re <br /> New Tanks Existing Tanks a.U in rn c.. 0 ts. <br /> Septic or Hultltng'1 ark /c C c'' ----., /DOCK l /ne 6i as t ❑ ❑ ❑ ❑ <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) Plumber's Signature' MP/MPRS Number Business Phone Number <br /> Steve Tesmer -r -`` i) - v/fr 227116 608-837-5297 <br /> Plumber's Address(Street,City,State,Zip Code) '::// <br /> N8458 CR O Waterloo,WI 53594 <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee �Dratee Issued lssuing�j?nt'gn. ure <br /> ❑Owner Given Reason for Denial $ • f . 3-2.9i"/J� <br /> IX.Conditions of ApprovalReasons for Disapproval <br /> RECFNFD <br /> JUL I 0 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> Public Health MCC <br /> SBD-6398(R03/14) Environmental Health <br />