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;��•�•, <br /> County 2 J <br /> t,�;k�.; � Safety and Buildings Division Dane �'!' <br /> .l� titi:_Cr�� W.Way and Washington Ave., Div Box 7162 Sant Ikcmd Number(to be tilled in Co.) <br /> i' '{',p.S 'i Madison,WI 53747 7162 <br /> -,'a4 13—dal-,— 0036$ <br /> Sanitary Permit Application State Trans:Mien Number <br /> to accordance with SPS 383.21(2),Wis.Mm.Code,submission of this Conn to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWrS are submitted to Project Address(if different than mailing address) <br /> the Department of Sofety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with.the Privacy Law,s.15.04(I Xm),Slats <br /> I. Application Information-Please Print All Information Prospector Lane <br /> Properi Owner's Name Parcel S <br /> t- Doug&Laurie Under 0811-124-0398-0 <br /> Property Owner's Mailing Address Property Locution <br /> 2999Triumph Drive Govt.Lol <br /> City,State Zip Code Phone Number - k, SE 14,Section 12 <br /> Sun Prairie,WI 53590 (circle one) <br /> 11.Type of Building(check all that apply) Lot* T. 8 N; R 11 E err W <br /> ®I or2 Family Dwelling-Number of Bedrooms <br /> cc., <br /> /1 5 Subdivision Name Bloat r/ Drovers Woods First Addition <br /> ❑Public/Commercial-Describe Use <br /> ❑City or • <br /> ❑State Owned-Describe Use CSM Nutrrbe ❑Village of <br /> e <br /> i Town of Sun Prairie <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A's ANew System ❑ <br /> f/ y Replacement System ❑TreWmcaUtiokLns Tank 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 /> 1 <br /> IV.Type of POWTS System/Component/Device: (Cltecicall that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Grown At-Grade ❑Mound 24 is of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank '❑Other Dispersal Component(explain) ❑Pretrcattnent Device(explain) <br /> V.Dispersallrreatment Area Information: <br /> Design Flow(spd) Design Soil Application Rate(gpdsl) Dispersal Area Required(s() Dispersal Area Proposed(sl) System Elevation <br /> 0'600 L/ 0.6 ,>.41500 0 98.4'&99.8' <br /> VI.Tank Info Capacity.in Total I or Monuracturer , <br /> Gallons Gallons Usrlts , S u <br /> New Tanks .Existing Tanks u 1 1 l 2 1 i <br /> d U iii .e en F.O a <br /> sepricorHaldingTook 1200 1200 1 Meade <br /> x <br /> Dosing chamber 800 _ 800 1 Meade x _ <br /> VII.Responsibility Statement I,the undersigned,assume responsibility for installation ofthe POWFS shown on the attached plans. <br /> P umber's Name(Print) P M14 ture MP/MPRS Number Business Phone Number <br /> ���- 1n&V.Deb-�,fK \ • zeivir( 1%2-1 to yQs?)-2o 1- ( o1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J-WI 15 4) f C iStrirti, 0\4 Kra v\G. wI 6-3711p <br /> VI Conn /De•artment Use On) � <br /> �� <br /> .. pprovcd ❑Disapproved Permit Fee f!T, `� �' <br /> • ❑Owner Given Reason for Denial S 1�-�6 ' _ _ �� — <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> / <br /> - ndf d>°ikk 10 c nra: 1 . co,,, <br /> Attack to cnInptete plans for the system and submit to the County only on paper eat less than$to s II Indus la also <br /> l k o t <br /> SBD-6398(IL 1111 l) at X. <br /> OCT 30 2017 t� <br /> PQbfk Health MDC <br /> 11Viinn--nan4.-1 u,_,._._ <br />