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!., SRrii, County <br /> Vr `Q Safety and Buildings Division Dane 6/;/ <br /> "p�ZL, 201 W.Washington Ave.,P.O.Box 7162 <br /> 9 Saniiory Permit Number(lobe filled in by Co <br /> Madison,WI 53707-7162 <br /> /3-J-0/) -cro 310 <br /> Sanitary Permit Application State TronsadionNumber <br /> In accordance wilh SPS 383.21(2),Wis.Mm.Code,submission(Willis form to the appropriate gov'rootcntal unit <br /> is restored prior to obtaining a sanitary prima_Note:Application forms for stole-owned POWTS are submitted to Protect Address(if different than mailing address) <br /> the Department of Safety and Professional Scrvies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Lass',s.15.04(1 Sm).Stars. <br /> I.Application Information-Please Print All Information LeFlore Court <br /> Property Owner's Name Parcel <br /> Norman&Cheri Kenney 0708-311-1371-4 <br /> Property Owner's Mailing Address Property Locution <br /> 12 Arboredge Way Govt.Lot <br /> City,Stale Zip Code Phone Numbs NE t,, NE <a-coon 31 <br /> Fitchburg,WI 53711 (circle one) <br /> II.Type or Building(check all that apply) Lot(t T 7 N; R S E or W <br /> ®I or 2 family Dwelling-Number of Bedrooms 3 / 21 . Subdivision Nome <br /> Block! Malmaison <br /> ❑Public/Commercial-Describe Use <br /> ❑City of • <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ®Town of Middleton <br /> III.Type of Permit: (Check only one box on line A.Complete line B If applicable) <br /> A. <br /> ®New System ❑Replacement System ❑Treatment/I lolding Tank Replacmmtem Only ❑Other tvlodi(icatbn to Edsling System(explain) <br /> B. ❑Permit Renewal ❑Permit Resistor ❑Change of Plumber ❑Permit Transfer to Nov 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 In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil r <br /> ❑Holding Took ❑Other Dispersal Component(esplain) ❑Prctrcatrnent Device(explain) <br /> V.DispersaVTreatmcntAres Information: <br /> Design Flow(gpd) Design Soil Application Itate(gpdsl) Dispersal Area Required(s0 Dispersal Area Proposed(sr) System Elevation <br /> 450 / 1.0 Or f50 462 -' 91.3',92.9' <br /> VI.Tnnk Info Capacity in Total S of Manufacturer <br /> Gallons Gallons Units - <br /> Nrry Tanks E isting Tanks e v i , <br /> r- N N ce a. <br /> Septic or Hahhng Tank 1000 l 1000 1 Crest x <br /> Dosing Chamber 600 - 600 1 Crest x <br /> VII.Responsibility Statement-1,the undersigned,ass nsponslbllity for Installation of the POWTS shown on the snitched plans. <br /> Plumber's Nome(Print) Plum•-s gnat• I'IP/MPItS Number Business Phone Number <br /> LS&P..O -' /oo70 Sf 4/2,‘-/-3o1 / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> rv'7 69 Cfr/4'/ D �//emst/e &i2 S3Sof <br /> VII unty/Department Use Only <br /> Approved ❑Disapproved Permit Fee Dam Issued Issuin gmture <br /> ❑Owner Given Reason for Denial S l e W <br /> I.X.Conditions of Approvol/Rensons for Disapproval <br /> .,:+7-c1 A101441) e,7" .9,vJ 9e6d- /w- »s 14'./#r7,1 e-0wD/r/or✓, <br /> 6YY9v#/0m.', az ✓,-"re&i6#Y 1 1tc '. /s <br /> Attach to complete plans for the system nod sot,mtt to the County onerep4Qhan N IG r 11 Inches lc she <br /> SEP 14 201 <br /> Public Health MDC <br /> Environmental Health <br /> 0 <br />