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County <br /> Safety and Buildings Division Dane ,'I Y <br /> ;17 ;::U'"` �'•`• 201 W.Washington Ave. P.O.Box 7162 <br /> a �l $P�t,, ' Madison,WI 53707-7162 Sanitary Permit Number(to be Glled in by Co.) <br /> Sanitary Permit Application StateTransaclwnNumber <br /> to accordance with SPS 383.21(2),Wis.Adm.Code,submission of this font to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application roan for state-owned POWTS ore submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Serv'les. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Puree!# <br /> ►Marco Martinez 0510-352-9530-0 <br /> Property Owner's Mailing Address Property Location <br /> v1-614 Old Stage Road C„L Lot <br /> City,State Zip Cade Phone Number SE n;, NW%, Section 35 <br /> ✓4rooklyn,WI 15/3521 608-449-4943 T 5 N; ti 10 (circle oon ) <br /> H.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 3 17.1 Subdivision Name <br /> Block it <br /> ❑Public/Commercial-Describe Use ❑City of • <br /> ❑State Owned-Describe Use CSM Number Village of <br /> ✓13829 Vl Town or Rutland <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A" ❑New System ®Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modifiwtkm to Existing System(explain) <br /> 0. ❑Permit Renewal ❑Permit Revision List Previous,Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Pressurized In-Ground ❑Al-tirade ❑Mound>24 in.or suitable soil ❑Mound<24 In.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design/low(gpd) Design Soil Aeolian Ralc(gpdsi) Dispersal Required(si) Dispersal Area Proposed(si) System Emotion <br /> V450 1/0.4 ✓1125 1128 V101.0' <br /> VI.Tank Info Capacity.in Total #of Manufacturer <br /> Cations Gallons Units o g <br /> •New Tanks Existing Tanks IN 3.t d 13 <br /> tJ rn , y EO <br /> Septic or]folding Teak 1/00/550 1250 1 Crest X <br /> Dosing Chamber <br /> ViI.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) Plumber's Signature IRf+/MPRS Number Business Phone Number <br /> flobev-t do$S7S- � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J,Z 5 G;nca/ii id t reii k lezi 53575>i— <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Data Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial Ak\ s)k INR‘ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to rnmpiela plans for the system viol submit to the County only on paper not less than A in x II[neha.� <br /> Cr-IN/ED <br /> N ED <br /> SBD-6398(R.11/11) <br /> Public Health MDC <br /> Environmental Health <br />