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`- �` i RECEIVE i County <br /> r1 Industry Services Division Dane IN <br /> fi v n 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co. <br /> aL-4:4 '•_, MA! L 4?U? P.O.Box 7162 r3 ��(' co 140 <br /> , Madison,WI 53707-7162 <br /> --,1 ;F Environmenta)Health <br /> Medrsuit&Dui l Lioun Sire Transaction Number <br /> Samtaly�'cii nt Application <br /> In accordance with SPS 383 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining sanitary permit-Noir Application forms forstate-owned POINTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Smits. Personal Information you provide may be used far secondary <br /> purposes in accordance with the Privacy Lamy,s.15-04(I)(m6 Stats CTH D <br /> I.Application Informntian—Please Print All Information <br /> Property Owner's Nome Parcel <br /> 0509-042-8110-0 <br /> John&Lydia Brown <br /> Property Owner's Mailing Address Property Locution <br /> 1611 County Highway D GovL Lot <br /> City,State Zip Code Plume Number NE v.. NW in,Section 4 <br /> Oregon,WI 53575 310-993-6728 (circle one) <br /> T 5 N; R 9 EorW <br /> II.Type of Building(check all that apply) Lot 4 <br /> ®I or?Family Dwelling—Number or Bedrooms <br /> 4 1 Subdivision Name <br /> / Block k <br /> ❑PubliGCommcrcial—Describe Use ❑City of <br /> CSM Number 0 Village of <br /> ❑State Owned—Describe Usc on <br /> 14702 n Town or Oregon <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X1 New System 0 Replacement System 0 Treolmenliliolding Took Replacement Only 0 Other Modification to Existing System(explain) <br /> ❑Change ❑Permit Transfer to Nc-a List Previous Permit Number and Dote Issued <br /> B. 0 Permit Rrnaval 0 Permit Revision of Plumber <br /> Before Expiration Owner <br /> IV.Type of POW'TS System/Contponent/Detice: (Cheer all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade 0 Mound>24 in.of suitable soil N Mound<24 in.of suitable soil <br /> ❑fielding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rnte(gpdsl) Dispersal Area Required(sl) Dispersal Area Proposed(sl) System Elevation <br /> 600 1.0 600 600 100.4' <br /> VL Tank Info Capacity in Total 4 of Manufacturer >, <br /> Gallons Gallons Units a c u c�m <br /> — <br /> New Tanks Exissing 7mtis --,g E a o. <br /> U 7, era a v <br /> Septiear Imlding Tank 1250 1250 1 Crest x <br /> Dosing Chmvber 750 _750 1 Crest x <br /> VII.Responsibility Stntement-I,the undersigned,assume responsibility for Instollatinn of the POWTS shown on the attached plans. <br /> Plumber's Name(Priniir Plumber's Signature Ir /MPItS Number Business Phone Number <br /> iii e(jc?r 12 r50it _ � - .,,1Ellct, 77S_02Y0 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -.6.—(Z 3si.) L16 c o/cq HO Ci Oe-eyz, h 14'°r 3-35:.- 6~ - <br /> VIII.Cooney/Department Use Only <br /> Permit Fee Dale Issued I gnMum <br /> "s ----.) <br /> tii Approved ❑Disapproved <br /> ❑Owner Given ReaS son for Denin7 I'312° 06/02/2021 erg-/n�je2. <br /> IX.Conditions of Approval/Reasons for Disnpprovai <br /> Protect mound site and area 15 feet downslope in its natur ondition. <br /> No compaction, disturbance, excavation, or vehicular traffic is allowed. <br /> Alanch to complete plans for thespian,rtnd submit to the County only en paper not less than ii to s 11 Inches In size <br /> SOB-6398(R.08/14) <br /> i <br />