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— s <br /> icit rI r 13 f'� , County' <br /> � ,. ..,..!rt <br /> y �fi�# _pefnicas Division Dane NI t)r <br /> !fir 4p 0A n . 7 r, 1400 'GVaStdrigton Ave Sanitary'Permit Number to he filled in byCo.) <br /> $ l • ![�I, Box• - 1 O. 7162 <br /> `'-#i ( Madison,WI-53707-7162 <br /> ='1.,; -A ' <br /> 7:- Enviren -mnun!Health /7-?.)(- pav <br /> I 141aJis a Gp I)e.0 iii Smlc Tmnsnction Number <br /> 0111 iy it Application <br /> In accordance with SPS 38321(2),Wis.Adm.Cade,submission of this form to the appropriate governmental unit <br /> is required prior to oblaining a sanitary.permit.Nate:Application forms for state-owned POWFS eresubmhlcd to Project Address(if different than nailing address) <br /> the Department of Safely and Professional Conics. Personal Information you provide may be used far secondary <br /> purposes In accordance with the Privacy Low,s.15.04(1)(m).Sats. <br /> I.ApplicationInfornintion-PleasePrintAllInformation Henry Road <br /> Properly Owner's Noise Parcel 0 <br /> Poseidon Properties LLC __ 0508-141-8740-0 <br /> Properly Owner's Mailing Address -"- •--- Pmpety Location <br /> 318 Ozark Trail, Go„.(At <br /> City,Slam - ritkank Phone Number NW ti, NE v.,Section 14 <br /> Madison,WI 53705 (circle one) <br /> 11.Type-of Building(check all that apply) Lot 9 T s N; a 8 E or w <br /> 01 oCl.Famity Dwelling-Number of Bedroaips.. <br /> 2 Subdivision Nene <br /> • Bloat 0 <br /> itPublic/Commercial-Describe l(c Office/Storage). <br /> ❑Cliof <br /> 0 State Owned-Describe Use CSM Number CI Village of <br /> 11511 ®Tounor Montrose <br /> III.Type or Permit: (Check only one box on line A. Congllete line B if applicable) <br /> A- )New System . <br /> y 0 Replacement System 0 T¢almemflidlding Tank Replacement Only ❑Other Modifiaotbn to Existing system(explain) <br /> IS, 0 Permit Renewal 0 Permit Revision <br /> 0 Change of Plumber ❑Pcrmil Transfer to New List Previous Permit Number sod Dine Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Systcnt/CourponenUDovicez (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground .❑Al-Grade ®Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area lnformntion: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(sq Dispersal Area Proposed(sf) System Elevation <br /> 160 1.0 160 160 101.7' <br /> VI.Tonic Info Capacity in Trial 0 of Manufacturer <br /> Gallons Gallons Units m y 6-E <br /> New Turks Existing Tela ' a <br /> vnv3 p. = oiter io . <br /> Septic or Holding Teak 1000 1000 1 Dalmaray x <br /> Dosing Climber 300 300 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume responslbllity fur Installation alike POSITS shown on tine attached plans. <br /> Plumber's Name(Print) Plumber's Sigr MP/MPRs Nwnber Business be <br /> Phone Number <br /> - ,T <br /> r,>toa .t r` -N -e.U.0 Iumnato <br /> f—Y.,) G� �a27s.2s woe qvs-7C1766 <br /> Plumber's Address(Strata,City,State,Zip Code) <br /> /330. Fr;Viz. Rd. Verp,Vnt (xl,1_ 5359 <br /> -PVr� County/Department Use Only Permit Fee Dam Issued Iss4Asea Sipdyae 444w/1e <br /> /��jApproved 0 Disapproved iS 310 '/,I 'u❑Owner Given Reason for Denial l to 674 <br /> IX.Conditions of Approval/Reasons for Disapproval it.S a 54 7\5 57GJ p4 7 1(a0 <br /> Protect&Maintain:0 Mound/ D At-Grade site anc-lirreirtiOwnslorrelfri s natural <br /> condition. No compaction,excavation,disturbance.or vehicular traffic allowed. <br /> -. Aunchtneampit ENSURE PROPER TANK SERVICE ACCESSIBILR Y: - <br /> Vertical Distance Tank Bottom(s)to Service Pad:4-15.ft <br /> SDB-6398(R.08/14) Horizontal Distance Tank(s)tQ Service Pad: '-ISC •ft <br /> Specific servicing mechanics must be provideii vertical is>15 feed <br /> horizontal is>150 feet.' <br />