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r•-• County iv <br /> t'1 , m Rat Industry Services Division DANE r <br /> '1 400 E.Washington Ave.,P.O.Box 7182 <br /> � f�' Sanitary Permit Numbs(to be Aliad in by Co.) <br /> •�-Y4 .�+�y Madison,WI 53707-7182 '5 <br /> d` i3— 4'01). 00 361-6"-- <br /> Sanitary Permit Application Sure TrenseetionNumber <br /> In eociwdmat whi SPS 3113.21(2),Ma Apr.Code.sobakedm elide hem to the impropriety governmental twit <br /> to regained prior to O6adeg a+.elan'matt Row Applies/foe tam Ox sM'•oyaadPOWTS ne wbt aid to <br /> the Department orbit/end Prorogued S its.Pelson!iatemelloayoeprodde may b evied fee meoaday Project Addrem(lfdllftrent Man mailing address) <br /> purposes le toeonlemee nib the Mew Law,a.11 04(1)(1.1,Sere. <br /> I. Appileatlon Intimation—Pleats Print All Information COUNTY HIGHWAY A • <br /> s Name N <br /> ROBERT&KATHRYN SWITZKY 0509.223,$080-0 <br /> Property Owner's Meiling Addtese Proper[.Location <br /> 1608 W.SOUTH ST. g....-Itl€+1., y., Seoron 22 <br /> City, Stets, Zip Code ?bone Number <br /> STOUGHTON,WI 53589 608 770-6906 . T 5 N,R 9 E <br /> B.Type afBailding(check all that apply) Lot N Subdivision Name <br /> EiiTyl or2Pan llyDwelling-NumberofBearooan: 4 Stooka <br /> 0 Public/Commercial-Describe Use CSMNamber O City of <br /> 0 State Owned-Describe use ty,13841 0 Vilbje of <br /> P' en of OREGON <br /> DI.Type of ermit: (Chick osly one box on line A. Complete line B if applicable) <br /> A. System 0 Replacement Swaim 0 Treatment/Holding Tank Replacement Only 0 Other Modification to <br /> Existing Swum(explain) <br /> & 0 Permit Renewal 0 Path Revision <br /> O chow ofPlumber 0 Perarit 7raae6tr to List Previous Permit Nuuober and Date Issued <br /> Before Expiration 1 New Owner <br /> IV.Type of?OWTS System/Component/Device: (Cad that apply) <br /> D Non-Pressarired ln.Grovmd 0 Pressurized ls.rrouud Et Grade O Mowtd k 24 in,ofeuftable soil ❑Mound<24 in.of nubble soil <br /> 0 Holding Tank CI Other Dispersal Component(expiain) 0 Pretreatment Device(expiNb): <br /> V.Dispersal/Treatment Area Information: <br /> Design Now ) Design Soil Pb9+t+o'n Rate(gpds1) Dispersal Area Requind(Sf) Maximal Area System Elevation —' <br /> t..- 0 0.6 4.--1660 112S 105.0 <br /> VI.Tank Info Capacity in Total Not Mmafac erir <br /> Gallons Gallons Gaits <br /> New Tula Umbra limb <br /> Septic a Beldam Teak 1286 • 1286 , 1 MEADE X <br /> /kaki 1a SOO 800 1 _ .MEADE X . <br /> VII,Responsibilityty,�Statementt I,the under as was rum nssibpfty for insWlailon of thpPOW T3 shown.on the attached pleas. <br /> e 1-rat l.*'iJ y//I Pt ,sJMPRSNumber BaslneuPhone et <br /> 3 a 7 Qv 9 . 6o�"- y9.4)"7/ <br /> bar's Address 6. ,, Zi. <br /> * _ 5- sa - <br /> VIII.County/DepirtmeatUse Only <br /> 51Appmved 0 Disapproved permit Fa <br /> `5$ <br /> `°0 <br /> O Owner Given Raison ll r Denial $ t14'" et-to 1011-411 x <br /> 'oCnditions otAppraval/Reasons for Disapproval 0 <br /> (Okra A-vat. s�w e4. .4.0A5 <br /> eu,SXosi.«As te4 ,k1a,. • �•e•., t4%. <br /> e.Xtb+A`Vaikt ,,sebeACA. aOC CAer Non ate,• RECEIVED <br /> Attach to complete plan Sr the mum yea submtmo be County oily on paper net ten tee S 1/2 x 11 latches in date SEP 2 1 2017 <br /> 318D4391(R.08/14) SCANNED <br /> Public Health MDC <br /> Environmental Health <br />