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• • .E'D71sj County GSf.;'_, ._ Industry Services Division Dane frI 0I_- ;fir B s'•:•-i;„,*. 1400 E Washington Ave sanitary Permit Number(le he filled in by Co.) '.`t P Ni P.O.Box 7162 -, a ti ¢rr Madison,WI 53707-7162 3 -d-tS a-/- 00/8p Sanitary Permit Application Sonic Transaction Number In accordance with SPS 3832(2),W is.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application farms For state-owned POWTS are submitted to Project Address(if dilrerent than mailing address) the Department of Safety and Professional Scrvia. Personal information you provide may be used for secondary purposes in occordance with the Privacy Law,s.15.04(1)(m).Sluts. I.Applicationlnformation-PleasePrintAllInformation Property Owner's Nome ,..... Parcel George B. Fink Rev.Trust &L56"")" '"/-{,_ 0506-252-9060-4 t—ei�_.� } P (//,/ kms,y,�.�ra�+/iS Property Owner's Mailing Address _ L r j_e� opoly Lo n 9674 Lee Valley Road (o'u f' govt.Lot tom-- 2L-, 2 t/ 1v"i�4^ City,State Zip Cede Phone Number -wag- SW Ill W/,,Scotian 25 :, Blanchardville,WI , �,.✓� 516 (circle one) IL Type of Building(check all that appI))' Lot g T 5 N; R 6 E or\V 61 I or 2 Family Dwelling-Number of Bain. 4 Subdivision Name Black O 20 Acre Metes&Bounds ❑Public/Commercial-Describe Use ' - • ❑CIty of ❑State Owned-Describe Use CSM Number 0 Villagtne . ®Tawii of Perry III.Type of Permit: (Cheek only one box o_n line A. Complete line B if applienble) A. I&New System ❑Re oeeinenl S pl ysteq( ❑Ttea(rrrenlaiokiing Tank Rcploccmrndy l d ❑Other Modification to Existing System(explain) t7C eWn f t i kcyis St - f�c puce 1.: hlzt�d 3-d j $r= in.5�t 014 .his B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permii Transfer to New List Previous Permit Ntttrliler and Date Issued Before Expiration Owner Sit - 137$/ z'Zi' O;g1/ 1 ei10 Rev 11/19/s7 IV.Type of POWTS System/Contponent/Device: (Check all tint apply) I i 4(i A-1..t,- '1—1S---2-o:A I t4 I7.4nq� ❑Non-Pressurized In-Ground 0 Pressurized In-Ground ®Al-Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.ofsuitable soil J ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) V.Dispersnl/rreatment Aren Information: Design Flow(gad) Design Soil Application Rate(gpdsl) Dispersal Area Required(s() Dispersal Area Proposed(st) SystemElevation 600 0.6 1000 1000 92.9' VI.Tank Info Capacity in Total /:of Manufacturer Gallons • Gallons Units ' L r u Nen Tanks Exislin;Tanks it t; 1/4 e Ti. t u-U in v: e.in c Septic or Balding Tank 1250 1250 1 Dalmaray x busing Chamber , 750 750 1 ( Dalmaray x VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shorn on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number \.r„CAhv IT -Se\\ ..__ d75a5 oto- '-i5-7-(EC, Plumber's Address(Stied,City,State,Zip Code) t33 t F.-rZ> i'd. •'s 3'J< WZ r -9'. . .......__._-------- - VIII.County/Department Use Only pproved 0 Disapproved Permit Fee D/atm Issued -Issuing -.t Signature 1 / • 0 Owner Given Reason for Denial atO Ij(�7�l2(9, / &4 p. j/!rj/f� IX.Conditions of Approval/Reasons for Disapproval X711 ' AT,-(0.}-.. , aygivi . Protect&Maintain:11 Mound/0/At-Grade site and 15 feet downslope in its natural condition. No compaction, excavation, disturbance, or vehicular traffic allowed. Attach to nemptete plans for Ito materl c;.,:v...,.....-:ha County linty nn paper nor Icon than A le x It Inches In aloe \sure tank locations are within 150'to all-weather service pad and within 15'vertical depth 'a` _i ':--e d:tference to all-weather service pad-Specific servicing mechanics must be provided if exceeded. � . . 47?o2) Existing Tank(s)and Drainfield to be properly abandoned prior to or as part of 1 Envifonmental Health replacement system installation,including pumping&reporting to PHMDC. Madison&Dane County -