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/ry-4,- County <br /> ;g%li .l...'�t Safety and Buildings Division Dane <br /> ,l1 D`14: ',.,_ 'i 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be liinedin by CO <br /> V.% If.,:r`` 1" Madison,WI 53707-7162 <br /> dr / — to�"�— vOi3�3 <br /> SaniCState TmnsactinnNumber <br /> wry Permit Application <br /> lo accordance with SPS 383.21(2),Wis.Ada.Code,submission of this.'Runs to the appropriate governmental unit <br /> is required prior lo obtaining a sanitary permit.Notet Application forms for stateenvned POWTS are submitted to Project Address(if difTcrent than mailing address) <br /> the Department of Safety and Protsstonal Sen•ies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,5.15.04(1)(m).Slats. CTH W <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel d <br /> Bill Wahlin, -- 0612-3048695-0 <br /> Property Owner's Mailing Address Property Location <br /> P.O. Box 278 Govt Lot <br /> City,Stale Zip Code Phone Number NE 'h, SE )4..Section 30 <br /> Stoughton,WI . 53589 (clrck one) <br /> 11.Type of Building(cheek all that npply) Lot H <br /> T. 6 N; R 12 E or W <br /> ®I or 2 Fondly Dwelling—Number of Bedrooms 4 2 Subdivision Name <br /> Block# . <br /> 0 Public/Commercial—Describe Use ❑city or <br /> ❑State Owned Describe Use CSM Number ❑Village of <br /> 14534 ®Town of Christiana <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. t <br /> ]New System ❑Replacement System ❑TreatmentAaold'rngTank Replacement Only ❑Other Modification to Extsting System(explain) <br /> Li <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New t Previous Permit Number and Date Issued <br /> Before Expiration Owner <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.ofsuitablesoil <br /> ❑Holding Took ❑Other Dispersal Component iexplpin) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: .. <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsl) Dispersal Area Required(s() Dispersal Area Proposed(s1) System Elevation <br /> 600 0.4 1500 1500 96.0' <br /> VI.Tank Info Capacity in Total Hof Manufacturer <br /> Gallons Gallons Units , o v <br /> New Tanks Existing Tanks �° a s i t .`$ 2 <br /> U rn .., to t=O n.. <br /> Septieor}taldbigMak 1250 1250 1 Dalmaray x • <br /> Dosing Chamber 750 750 1 Dalmaray x <br /> VII.Responsibility Statement 1,the undersigned,assume rresponsibtil •for Installation of the POWTS shown on the attached plans. <br /> P 's Namf(P_rint) _-'s Si .urn MP/MPRS Number Business Phone Number <br /> . �� r - ' e Jas ,A3 ( ,0(6-41-14-erg, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> proved ❑Disapproved Permit Fee 'QDam Issued Issuing t Afrikr- <br /> IX ❑Owner Given Reason for Denial S l J f•fl v� 2'7 /Conditions of Approval/Rensons for Disapproval <br /> 4 w••lk VA sa.s4r■-% 1 J.•I.ro f-at-i7•It <br /> At h to complete plans for the system awl submit to the County only on paper act less than 8 r2 x 11 InelitsE(E i a .E <br /> SBD-6398(11.I I/I I) AUG 21 2017 <br /> - SCANNED <br /> Public Health MDC <br /> Environmental Health <br />