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, ... <br /> County <br /> Safety and Buildings Division Dane MCI <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)" <br /> Madison,WI 53707-7162 <br /> i 4-)11 — ( 3Ce <br /> Transaction Number <br /> Sanitary Permit Application State <br /> In accordance W t h SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safely and Professional Scrvies. Personal information you provide may be used for secondary .. <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Sults. <br /> V 1256 Hwy 14 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# • <br /> John &Sandy Ziegler fr"0510-072-8230-9(parent) <br /> Property Owner's Mailing Address Property Locution <br /> W1449 Alpine Road , / <br /> .,Covt.Lot <br /> City,Stole Zip Code Phone Number NE v,, NW V. Section 7 <br /> Brooklyn, WI 53521 (circle one) <br /> T 5 N; R_10 E or W <br /> II.Type of Building(check all that apply) Lot# <br /> 0 I or 2 Family Dwelling-Number of Bedrooms ' 1 Subdivision Name <br /> Block 4 <br /> E Public/Commercial-Describe Use Office/Shop <br /> 0 City or <br /> CSM Number 0 Village of <br /> 0 State Owned-Describe Usc <br /> fil <br /> 4281 (current) Town of Rutland <br /> III.Type of Permit: (Check only one hox on line A. Complete line B if applicable) <br /> A. Ki New System 0 Replacement System 0 Treatmentillolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> li Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpds1) Dispersal Area Required(so) Dispersal Area Proposed(sf) System Elevation <br /> 230 /0. if' 575 /750 Equiv. 88.8' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> V. 4 <br /> Gallons Gallons Units <br /> New Tanks Eliding anks 'E .1! 1; I' 1. <br /> LL.0 =. <br /> 1 Septic er Holding rank <br /> 700/550 1250 1 — Crest x <br /> I , <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigne ,-.7.—iiiiizifitbItity roe Instaitrition-a-tla POWTS situntribtl thr_atinehed plans. _____, --- <br /> Plumber's Name(Print) 7,,..---r"Lipp; Siiniur5( ) cu./toms Number - iiiiness Phone Number ------.. <br /> ----.. <br /> '‘ <br /> R0 la 04a( i-:,, s, #' ( } "Zg /7 r3 ..,0a4-S75- <br /> _--L- <br /> Plumber's Address(Street,City,State,Zip Code ' —..-- ___ <br /> it) . 44/1 a,A Si- (f) <br /> /Al a.", Grd I c3.5-7 S--- <br /> VIII.County/Department Use Only <br /> Permit Fee Dale ssued Ining Agent Signature <br /> Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial S 05'1- \IA 19 IV _ilipilid. ray <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system nail snbmit to the County only on paper not less than II la a it Inches In size <br /> !;,): ,...., .:7 4 ,, 1-:---tl ') <br /> -, '1 Ts:'-.--7.-: .'......i. ':.t.f <br /> SBD-6398(R.11/11) -- - <br /> NOV 2 :) 2017 <br /> --___ <br /> . —_--_ <br /> c'u.'tlic P..-all:h 1,IDC <br /> 47mi ;-*.prk-',,m,..a.::±ta! Health <br />