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i� �_ County <br /> / f ,,..' Safety and Buildings Division Dane t I Li <br /> B `a. ,\W 201 W.Washington Ave.,P.O.80X 7162 Sanitary Pernik Number Ito be Stied in by Co.) <br /> 1r� S11"r i Madison,WI 53707-7182 <br /> Sanitary Permit Application stmeTmnseelimnNamber <br /> to accordance with SPS 38311D),Wis.Ado>_Code,submission of this form in ha eppmprate govenmmtd unit <br /> is required prior to obtaining a s®kay permit.Nag Appl orlon fonts far stele owned POWER use suhodtted to Project Address(If different than mailing address) <br /> Um Department of Safety mod Pmtessiond Se vies.Personal inknution you provide may be used foe secondary <br /> paposes in aceaderns with the Privacy LOW.s.I5.04(1 xm1.Slat. Center Road <br /> L Application Information-Plisse Print All Information <br /> Property a s Name Parcel <br /> .Timothy&Kathleen Wilson x0510-222-8660-7 <br /> Property Owner's Mailing Address Property Location <br /> x1300 Garden Avenue <br /> City,Slate Zip Code Phase Number t NW Yes Senior 22 <br /> Stoughton,WI ( :.:ti 698-2118 {dr&one) <br /> T 5 N R 10 <br /> II.Type attending(cheek all that appl Lot A <br /> ®1 or2 Flunky Dwelling-Number orHal• ,• 3 ,/'t SobdividanNome <br /> Block A <br /> ❑Public/Commercial-Desenw _e vac ❑City or <br /> ❑Slate Owne- Use <br /> CM Numkc ❑Jwlogeor <br /> 661 ,I.9 Town or Rutland <br /> III.Type of Permit:(Check only one bus on line A.Complete line B if applicable) <br /> A' ®New System ❑Replacement System ❑Tremeneadlio18ogTank Replacement Only ❑Other Moamadoe to Existing System(eatplain) <br /> B. 0 Permit Renewal Q Permit Revision ❑Change of Plumber ❑Permit Tnmisfa to New <br /> List Previous Permit Nnanbe•and Date issued <br /> Before Etpintiee Owner <br /> IV.Type of POWTS Systene/Compooent/Device;(Cheek an that apply) <br /> ®Nan-Pressvriad In-Ground ❑Pressusixd la-Ground ❑At•Gmde ❑Mond>24 id ofsaitoble seal ❑Maned<24 in.of sukable sal <br /> ❑Holding Tait ❑Other Disperse!Component Insplin) ❑Pretreatment Device(espain) <br /> V.Dispersal/Treatment Aren Information: <br /> Design Flow(gpd) Design Sall Application Rntggpdai) Diapers l Ales Required(sr) Dispersal pea Proposed tu0 System Elevation <br /> .450 0.4 1, 25 i.f128 93.4' <br /> VI.Tank Info Capocilyin Taal Of of Mmwfocnrce <br /> Gallons Gallons Units al Al <br /> **Tanks E wn Togs ay <br /> r SU A3 w /r.0 it <br /> r,5gaic or lldd:ra Took 1000 1000 1 Dalmaray x <br /> Member 600 600 _ 1 Dalmaray x <br /> VII.Responsibility Statement I,the undersi• mane respo for Installation of the POSTER shows on the'linefeed Mmes. <br /> s Nmne(Print) s me hIPIMPRS Number Bushes Phone Number <br /> ck�� s QDv3y3 (,,on--tiY-k-as64 <br /> Plumber's Address(Street.ay.sate,BP Code) <br /> 1e 4c.V\lei �� \)e. ,.'S- <br /> VIII.County/Department Use Only <br /> md„ppeuved ❑Dial Permit Fee Date ima0. - At me <br /> ❑owner Given liaison for Dmal S■.5 <br /> '"f 3 I 1/ IY -1\1140. ti IX.Conditions of Approvaf/Rensons for Disapproval <br /> Armek to comptnlepleas for the system and submit Is the Comb-only on inner net less than I n z 11 locks le stip,; <br /> SBD-6398(R.11/I l) ',c JFI!ED -- <br />