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rt�u'�riy• 1 County <br /> �� �•\ ( Industry Services Division Dane <br /> 11(� :,-.)...;1,,,,, s it <br /> .:'D1.T, '1 i 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> :, iv S- ,-**i.F l i P.O. Box 7162 <br /> ria tl; <br /> 12-�ti. 1 rr Ton ,�.u ' ,I h Madison,WI 53707-7162 — i0 2-i_ 00 061 - <br /> -'71/Z1:4:' ,'" <br /> State Transaction Number <br /> Sanitary-PerinituApplication <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission adds form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POIVfS are submitted to ProJect Address(if dilicrent than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All lnformation Tower Line Road <br /> Properly Owner's Name Parcel 4 <br /> Valli Warren 0812-261-9240-0 <br /> Property Owner's Mailing Address Property Location <br /> 1824 W. Main Street Govt.Lot <br /> City,Slate Zip Code Phone Number SW ,, NE %, Section 26 <br /> Stoughton, WI 53589 (circle one) <br /> H.Type of Building(check all that apply) Loth T 8 N; R 12 E or W` <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 4 Subdivision Name <br /> Block k <br /> 0 Public/Commercial-Describe Use <br /> O City of • <br /> State Owned-Describe Use <br /> CSM Number 0 Village of <br /> 14601 1g Town of Medina <br /> IiI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. E News stem 0 Replacement Sstem 0 Treatment/Holding Tank Replacement Only <br /> 0 Other Modification to Existing System(explain) <br /> R• D Permit Renewal ❑Permil'Revision <br /> 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade -0 Mound24 in.of suiiable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Infornrntiotts <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(at) Dispersal Area Proposed(s1) System Elevation <br /> 450 0.4 1125 1128 102.9', 104.9' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> sl <br /> Gallons • <br /> Gallons Units s E o $ <br /> New Tanks Existing Tnnls d y " u . 12 •g <br /> el..U in sra i=C7 is. <br /> Septic orHolding Teak 1000 1000 1 Dalmaray x <br /> Dosing Chamber 600 600 1 Dalmaray x <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility Tor Instafatian of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MIP/MPRS Number Business Phone Number <br /> /14 4,W 1/i /Z-a.SG:.IZ -a X, -- .x-311 a-S &03- 5'717-3,)--i ? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> R'7 a-- Sto-{-e- cud tag-, 5-fotr 6'v d'1, r."• 535e-) <br /> VIII.County/Department Use Only <br /> ]�Q Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 3 I <br /> 0 Owner Given Reason for Denial 464.00 _ 04/28/2021 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attnch to complete plans for the system and submit to the County wily an paper not less than 8 1rz s 11 Inches In size <br /> SDB-6398(R. 08/14) <br />