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ti County <br /> U, rr <br /> ;i7 �K� Industry Services Division DANE t <br /> 1400 E.Washington Ave.,'P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 , <br /> �% ti- —,) I '._ e3c,0 0 -.., <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Mm.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 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(lXm),Stats. <br /> I. Application Information—Please Print All Information 848 STORYTOWN ROAD <br /> Property Owner's Name Parcel# <br /> ERIC&CAROLANN NELSON r'Ei <br /> 0509-202-(retired 9/21/17) <br /> Property Owner's Mailing Address Property Location 65-4Cj- :.)c3- k. 0-- <br /> -- <br /> 2802 MOLAND STREET NW %, NW r/., Section 20 <br /> City, State, Zip Code Phone Number <br /> MADISON, WI 53704 608 516-0335 T 5 N,R 9 E <br /> III.,Type of Building(check all that apply) r Lot# 1 Subdivision Name <br /> [ family Dwelling—Number of Bedrooms 3 Block# <br /> ❑Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use 14606 ❑Village of <br /> D T of OREGON <br /> f II rf I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> I <br /> 1 B <br /> ' 0 Permit Renewal 0 Permit Revision 1 Change of Plumber 0 Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration - New Owner <br /> I i IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ( i ound s 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain):Eljen B43 product <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.8 562.5 570 98.15' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units :? a a <br /> New Tanks Existing Tanks 1. i U °r T, 13 3 <br /> oB.. a A' <br /> n a it- 3 a. <br /> Septic or Holding Tank 1000 1000 1 DALMARAY X <br /> Dosing Chamber 600 600 1 DALMARAY X <br /> VII.Responsibility Statement-I,the un ersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Prin PI .er's Si . ; e ,/' MP RS umber Bus-irl s Pjtoty,Num er <br /> l ,k i) I S I �— L/a�L-Y Sri! <br /> Plumber's Address.( State,Zip_ ode <br /> 7S 7 � r3ele�1te i.�� 5350F <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issi}e(114'4\--------t-- <br /> I uing Agent Signature \\ <br /> ❑Owner Given Reason for Denial $ CI ( " \ L1 I I •if� <br /> IX.Conditions of Approval/Reasons for Disapproval 1 <br /> (at/ cc o Saki, V \S arc t,{ ,o..lpS\ote.. ' e.',c..vo�\0(\,Cj? r ' :S'4.cb crc�,OC <br /> 4 ._I i:..4 ..,.`.l J Q�u-1 FC k c r+V6 t. Q�1 1•11 .• _v f tU 1l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 rotas ,si e3 i <br /> SBD-6398(R.08/14) <br /> SCANNED <br />