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�-1:4•' ''';� County Dane K <br /> 4 ,10,..e ..j Safety and Buildings D)Vlsion <br /> A I °D=.4� it r j` 201 W.Washington Ave.,P.O.BOX 7162 Sanitary Permit Number(to be filled In by Co.) <br /> P•-d MadIson,WI 53707-7162 <br /> it ;144:S1 */ <br /> 1,1.....,..„ . <br /> ` �' I 3- �°'�(--) doh b 3•SlateTranmciinn Number <br /> Sanitary Permit Application <br /> In accordance With SPS3113.21(2),Wis.Mm.Code,submisslonofthiis formic ttie exeunt tale go{•ernmenlnIUntl . <br /> is required.prier to obtaining a soldiery pentiil. Nalet Appiimtlpn fawns;rorstatvoivned POWfS are..sribmitied to "Project Address:(if different titan mciliny,address) <br /> dm Department of safety sad l'rorssioiml Semits. Persona)ihrortr glen you provide may be used for secondary <br /> purposes in accordance with the Privacy Law..s.13.t)4(l1(ml.Slats.. / UN I A <br /> 1. AppIIeation infornrntlon-'Please Print All lnrormation J p <br /> Pmpen "timersName• Pared#0. /p - /S‘4 p U-- 0 <br /> Mathew&Jacqueline Oliver y _ <br /> Property Owner's Mailing Address :Propaly..Location <br /> 2225 Stone Crest Road qy;i.Lol <br /> 'City,Slain • . Zip Cade Phil oNUnrher 2/ NE !4, SE !IA,:Seelton. 13 <br /> Stoughton,WI /`53589 (circle one). <br /> U.Type of Bulld(ng.(chaelt nil ttrnt.npply): Lot* <br /> T.. 5 N; 'tt 10 E or 1Y <br /> . <br /> 3 2 Subdlv(sio n'Name <br /> M I or_Family Dwelling.,Number-of Bedmor s ':' <br /> Bieck# . <br /> 0 PubUc/Commetsial-Desixibc Use <br /> 0 Cily of • <br /> El n State O earl=Describe Use CSM Number ❑Village or........................ .. <br /> 14503 j l Tray of Rutland <br /> III.Typ f Permit; (Checironly one hex on line A. Complete line B If nppficable).... <br /> A :New System EI-Replacement System .0 Treat inentllliIU gTank Beplacemenl Only 0 Other Modf�eatten to Existing:System(explain). <br /> B. 0 Permit Renewal 0 Permit Revision 0 Chopge of Plumber 0 Pena Transfer to New List PrevioadPeanil Number and Dale issued <br /> Before Elvin,Ilan Onmrr <br /> IV,Type orpowrs System/Component/Deviccr::(Chechal1 that'apply.) <br /> 0 Non-Pressurised In-Ground 0 Pressurized.ln-Ground 0 At•Giatle 0 Manna>_?4 in.of suitable soil rgI Mound.<?a in..disyllable sail <br /> . <br /> 0 Holding Tank 0 Other Dispersal Component(espiiin) .. 0 Pretreatment Device tplain) <br /> • <br /> V.DispersnVrrcntmetit Area Information: <br /> Design Flow(gpd) Design Soil Application Ralc(gpde): .Dispersal Area' ,(st) Disperse!Area Proposd( J Sysi pi Elevation <br /> 450 1 (I,( 4 `-;C_ 4 III. " 99.5' . <br /> VI.Tank Info J'opa lty,iii alai N of : M :Utterer <br /> Gallons : Gallons Units e o w • <br /> New Tanks h t Fsag Tanks a c v 'a 1. i <br /> I'd y w y rc.rJ a. <br /> • <br /> septic ar;Wise Task 1000 1000. 1 Meade x <br /> Dmtnectramber 650 650 , 1 Meade x _ <br /> VII.ResponsibUity Statement-1,the underslimcd,azstinre responsibility furlastaliatlo f the POINTS shown an the attached plans; <br /> Plumber's Name(Print) Phmnber's Signature •t.P/MPttS Number Business Phone Number <br /> th-vtve-v./ W•MU►*'&2 (.--.-4t�t.-- w. 2za(te5 831-ato3 <br /> Plumber's Address(Street,City,Stale.Zip Code) <br /> X13 C-i-y_ 44 •■. V. ir...Guth , V 5357 <br /> V111.Coon 1De artment Use Onl �I --.7.N\T <br /> pprovd 0 Disapproved PerrmlI Fee - Date lssul A L �/ <br /> 0 Omer Given Reason for Denial S 1 P1 ii .' <br /> IX.Conditions of Approval/Reasons for Disapproval • <br /> 's-------.-L------FZEC F I V E D <br /> Attach to cmnplela plans far the system unit submit to are County only an p'ripernol Ices Than a tL z it lashes In size JUN 0 6 2017 <br /> Public Health MDC <br /> SBD-6398(R.I I/1 t) SCANNED NN Environmental Health <br />