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' 1,.q fII <br /> if ./Z--- �i <br /> JUL 242008 J <br /> corninatce.vd.gov Safi ty and Buildings Division County <br /> isconsin. a,Public Health MDC 201W.V�ashington Ave.,P.O.Box 7162 Dane <br /> ilai �a '.Ith Madison,WI 5 3 707-7 1 62 Sanitary Perrot N be filkdm by Co.) <br /> ntaf�roe `i` `U 9Q <br /> Sanitary Permit Application St eTr n S 9024 <br /> In accordance with s.Comm.g3.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application fortis for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Inspirers in accordance with the Privacy Law,s.15.04()Xm),Stets. 3854 Deerfield Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel 0 <br /> Dale Miller 0711-241-9910-3 <br /> Property Owner's Mailing Address Property Location <br /> 3854 Deerfield Road <br /> Govt Lot <br /> City,State Zip Code Phone Number SE 'h, NE v.., Section 24 <br /> Deerfield,WI 53531 764-1303 7 N, R 11(cirt(circle <br /> Type of Building(check all that apply) Lot g T <br /> tJ I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block l< 0.63 Acre Metes&Bounds <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> E Town of Cottage Grove <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. ❑New System ®Replacement System ❑Treatment/HoldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List 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 hi-Ground ❑At-Glade OMound>24 in.ofsuitabk soil ❑Mound<24 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DisperaaVPreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(at) Dispersal Area Proposed(si System Elevation <br /> 300 1.0 300 450 _ 102.6' <br /> VI.Tank Info Capacity in Total g of Manufacturer <br /> Gallons Gallons Units 3 3 ea <br /> New Tanks Existing Tanks 3 <br /> i91 H is 3 P, <br /> Septic er Holding Tank 1000 _ 1000 1 Crest x <br /> Meng Chamber 600 600 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume removability for listaliatlea if the POWTS shown on the attached pines. <br /> Plumber's Name(Print) D K Plumber's S' tyre--� MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,Stale,Zip Code) r <br /> I l�(J l � <br /> (OLD ;in C c, a •n� fl/L. r cLg 3'I.-, (,:J j p,VIII.County/Department Use Only l <br /> J°' pproved ❑Disapproved Perini -' Dot lss um-;11 .. �/ <br /> ❑Owner Given Raison for Denial � 2 O� ��� r � ' <br /> IX.Conditions of Approval/Reasons for Disapproval ` <br /> i <br /> Attach to complete plass for the system sod submit to the County only on paper not Ina than a vs a t l lathes la fire <br /> `Di3 1 U(Q , Ci- K 1f3aq 7 <br /> SBD-6398(R.01/07)Valid than 01/09 <br />