Laserfiche WebLink
��y+ `v; County <br /> /441):4.::'1 Safety and Buildings Division Dane <br /> r ,11 •`_:i, i 201 W.Washington Ave.,PA.BOX 7162 Sanitary Permit Number(to be filled in by o.) <br /> ' °S P; Madison,WI 53707-7162 <br /> ,;, /3-.oi7- 003 001-- . <br /> Sanitary Permit Application "o Transaction Number <br /> to accordance with SPS 38331(2),Wis.Aden Code,submission of this foot to the appropriate governmentai unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS ore submitted to Project 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 Law,s.15.04(1}(m),Stars. Getz Road <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Chad &Cheryl Hoff / 0607-062-2105-0 r • <br /> Property Owner's Mailing Address Property Location <br /> 596 Pease Road Govt.Lot <br /> City,stale Zip Code Phone Number NW �;, NW , section 6 <br /> Pardeeville,WI �;:-83Q64 T 6 N, 7 (circle one) <br /> Ii.Type of Building(check all that apply) \ Lot# or W <br /> ®I or 2 Family Dwelling-Number of Bedrooms C4 - ) 3 Subdivision Name <br /> j Birk it . <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑Village of <br /> 14112 ®Town of Springdale , <br /> / <br /> III.Type of Permit: (Check only One hox on line A. Complete line B If applicable) <br /> A' ®New System ❑ <br /> yst Replacement System ❑TreotmenUliolding Tank Replacement Only ❑Other Ivlodi[icatton to Existing System(explain) <br /> / <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Dale 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. <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(si) System Elevation <br /> 600 ' 1.0 600 600 99.3' <br /> Vi.Tank Info Capacity in Total g of Manufacturer <br /> Gallons Gallons Units g o v <br /> • <br /> New Tanks Existing Tanks =e' 3 <br /> Septic or Holding Tonic 1250 1250 1 Crest <br /> x <br /> Dosing chamber 750 750 1 Crest x <br /> ViI.Responsibility Statement-I,the undersigned, me responsibility for Installation of the POWTS shown on the attached plans. <br /> Plunder's Name(Print) PI s Signature Ivii'/MPRS Number Business Phone Number <br /> -7-175" u(s lcx zog2 _'l 30'y <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /U7&9 CirrmI f) l efI 4ae Ss' --_a---._.s.. _ . <br /> VII ounty/Department Use Only <br /> Approved ❑Disapproved Permit Fee(,./ Date Issued, Issuing = tS' „ere 4e,l� <br /> ❑Owner Given Reason for Denial 1/ t`e' 09/ /I 7 ./ <br /> I.C.Conditions of Approval/Reasons for Disapproval <br /> !-•rr el` ,491110v7, s rec 044 00100■ 'RA-AO rF�r Abwoti�es•AW. _".,ie //7„y N.erges , <br /> 4,wDITyI,V. /Yo ea.rwe ?-"•,a-- i P",- cit�vi e-, .�.y"ao�l, _ �A I/hie/ewe-i(C 7 qc,C <br /> , l5 04/Gw-FE,. . <br /> Attach to complete plans for the system and submit to the County only an paper not los than a la s II Inches In size <br /> • <br /> 1 <br /> SBD-6398(R..11/11) <br /> CANNED SEP 0 7 2017 <br /> Pubitc 1+aaltt•; MDC <br /> Environmental Health <br />