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tIt County <br /> /, Safety Buildings Divisiolt. Dane iZl(:f- <br /> 1 ,, a 201 W.Washington Ave.,P40.Box 7162 Sanitary Permit Number(to be flied in by Co.) <br /> '? ttu'pf'� Madlsati,wi 53707:T102 <br /> v_ <br /> *miiCt? j f (4 € <br /> ` C C L } <br /> c <br /> Snitary Permit Application Ste"fimts lonbiuuibYr <br /> In accordance with SPS 383.21(2) Wis.•Mm.CO;submission utf thss_form to the appropriate governmental unit <br /> (s-requifedpriorte obtaining iisunttaty pcfmL.Note;:Appbcntinnfotms:for:state-onmedPOWlSaresubmitted to; .Project Address(i[differentthammailingaddress) <br /> the Department o f Snfely'and Professional Serf acs. Pe sanal.inforniatton youpmvida.maybe used for seeondery <br /> purpoies in aecontanee With the i'nwcy LAW s.15.00)(rol;Slats Hwy 51 <br /> 1.ApplicuuionInr'ortuatlou-plensePritttAllIiifornmtIon . <br /> Propelly.thtmer's:Nmne Parcel# <br /> Theran&Mia Kahl 0512-053-9700-7 <br /> •Property Oiuer's•MallingAddless: .. : Ptut,atyLocntiun <br /> 1172 Maple Grove • .. . . Govt.Lot <br /> -City Slate • ZipCode Pitone-Niitnbet• SW 64, SW 4;:Sentign 5.. <br /> Stoughton,WI 53589 . 608-577-7651 • <br /> 08-577-7651 12 _teireleone) <br /> T 5 N; S. _EarW <br /> H.Type ofliulttlingg:(ebnck:tilt thattifijsly). W Lnt# <br /> t of Fondly t)welling-NwuberofBedrooms 4 1 Subdivision Name <br /> Bieck# . <br /> 0 Pubiic/Commereiat-fiesiribc Ilse ' • <br /> 0 City ol', <br /> • QStateQvnct'—Dscdiaisc, CSM 7ilttber ❑Villpge of <br /> "---..._ <br /> 2384 . a ToWI:of. Albion <br /> ill..Type of 3'ernilb (Cheek anly:one box'on ifiie_A. Coinpletef'dsOaffnppI(cnbie} <br /> i"••• ®-New System El Rol)iacefient System 0 Treattnent/Bbit.frefunk Reptaaecmeni Only ❑Other Mod!(ieation to stingSystem(eaplaln) <br /> R. D Permit Renewal •D`Permit Revision D Change ofiihntiber D Parmit Transferto New <br /> List Previous Pi mit 1't;mber add Date issue d <br /> - Belbrc.Ex,hation . Owner <br /> 1Y.:-Type of POWTS Sy tem/ComponentIDes ee: (Check'nittlttit'apipi3:) <br /> i]Non-Pressurizedtn-Ground Dl'ressurieedIn-Ground it Al-Grade :0 Mislaid>24"m.ofsuitablesnit ❑.Mound<?4in,ofsuitniksoil. <br /> Dto1di1gTank DOtha)ifpetsoGu aponent(explain) .. .D.Pretreatment Device texpiain) - <br /> Y.11lspersoltrreatrnentAr:eg lnformnt(on . <br /> Design,Flowespd) Des iglteSoliAppileationRele(gpdsl) ' Dbpereai.Area.ltequired(sd) Dispersai Area Proposed(si) SystemEievatloit <br /> 600 0.4 1500 1512 . _ 96.0,97.3,98.6' <br /> VI.Tank Info Capacity.in ' Totes #of • Manufacturer <br /> Gallons aelloas Units 5 a. 1, <br /> Ntw Tones ExistingTmths . '2" .23. I <br /> o d <br /> 0.C) ill.w r.O t4 <br /> SSopitaerl9ON%Teak 1250 1250... 1 Crest • x <br /> ooshrgChamber 750 50 1 _ Crest x <br /> VII..ftosponstbility$tatement t,the undersigned,use no pltf lorinstal of the PtnVfs.sliu n on the attached plans. <br /> Plunder's Name(Print) Plumber' on IP/MPRLS Number Business PhoneNumber <br /> 'trr•/ `Lc1/4.\"1 I , aa'f \`d 5. (6°$)V3--365 1 <br /> Plumber's Aildress,(Strect,C,ty;State,Zip Code) <br /> 36s l's.&0s ;,-.\ C;( 5k-0 ).0-, Lj\ 53 5--2 `t <br /> / <br /> VIII.County/Department-Use only <br /> Pe <br /> Appmvcd D DisonprovePermit Fee Data issued issuing S t <br /> s 2 21-2°!S <br /> D(hvnerGiien Reason for Denial §-01/4— <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plane for the spasms neut submit to the County only on paper not less than a it/z I i inches In size <br /> SBD-6398(R.I1/I1) � `' <br /> • FEB 2 7 2U11 <br /> Public He:ith i ADC <br /> Environmental Health <br />