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t.‘}174. .\Ot County D (-1 <br /> ,7 1t Industry Services Division DANE <br /> S <br /> t 1400 E. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' •. vt,% Madison, WI 53707-7162 /3-d O/7- OC )P <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 permit.Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies. 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),Stets. Pa rAel 9- ii <br /> I. Application Information—Please Print All Information SAME o 1i(- ($t- 60c0` <br /> Property ner's Name Parcel# <br /> C THOMAS& KIMBERLY PORTER •"------69-n-181-8210-0 <br /> Property Owner's Mailing Address Property Location / <br /> 3136 HAPPY VALLEY RD. s-�NE '/,, NE '/., Section 12 <br /> City, State, Zip Code Phone Number <br /> SUN PRAIRIE,WI 53590 608 516-2928 T 9 N,R 11 E <br /> II.Type of Building(check all that apply) -'\ Lot# l. Subdivision Name <br /> 1 l <br /> 1 or 2 Family Dwelling—Number of Bedroom/ 3 )3lock# <br /> ❑ Public/Commercial—Describe Use '/CSM Nu2ker ❑City of 11111111111❑State Owned—Describe Use 4419 ❑ Village of <br /> GV n of BRISTOL <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Cd•New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New 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 Q"Mound S 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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450650 '� 888.75 103.4' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> o u y New Tanks Existing Tanks u ° F tel n <br /> _ n. s) i7) rn rr 5 a_ <br /> Septic o1dd'i,g Tank 1000 �^ 1000 1 CREST X <br /> Dosing Chamber 600 -- 600 1 CREST X <br /> VII.Res i onsibili Statement-I the undersi'ne. assume res u onsibili for installation of the POWTS shown on the attached I tans. <br /> Plumber's Name(Print) A/('" . is iftir,tu e MP/MPRS Number Business Phone Number <br /> JOHN E. RASMUSSEN T1 / f` 223-732 (608)635-4305 <br /> Plumber's Address(Street,City,Stag'ip Code) <br /> ARLINGTON HARDW•RE CO., INC., P.O. BOX 169, ARLINGTON, WI 53911 <br /> VIII.County/Department Use Only . <br /> .approved ❑Disapproved Permit Fee i Date Issued Issuing Bent•Sii atur <br /> q `� `� �r1 <br /> ❑Owner Given Reason for Denial $ I d' b ?—it ��� C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> K Rjevy�fL�pe ' a <br /> PR�e,T fro O syf?� J t 7P 4" AREA ' <br /> S014 CoiiA(Ar_0", .1714 C-y--C/l 14'" D II*Q-17 G(, 474_ 7i' RECEIVED <br /> PRo��7 n1 i i c r.ff *r c ar7� <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 /> JUL 2 0 2017 <br /> SBf fV=$,([2�4�4'�/�A1 ) Public Health moc Environmental Health <br /> • <br />