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• <br /> • <br /> /rim 17, Industry Services Division County Dane yvlbL <br /> r�r p 'i z-c, } 17l" 1400E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> yr ;_.S Si P.O.Box 7162 <br /> \"•�ti' �w Madison,WI 53707-7162 <br /> Sanitary Permit Application Stale Transaction Number <br /> In accordance with SPS 38121(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to oblaining a sanitary permit.Note Application forms for state-atoned POWTS ore submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Scrries. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy loss',s.I5A4(I1(m).Stats. Cobb Road <br /> I.Application Information-Please Print All Information y <br /> Properly Owner's Name Parcel <br /> II <br /> Kevin&Brittany Campbell 0607-324-9005-0(parent) <br /> Properly Owner's Moiling Address Property Location <br /> 507 8th Street <br /> Govt.Lot <br /> City,Slate - Zip Code Phone Number SW ;:, SE N,Section 32 <br /> New Glarus,WI -63574 <br /> 608-24-1613 (circle one) <br /> It.Type of Building(check all that apply)r Lot y T 6 N; R 7 E or W <br /> ®I or 2 Family Dwelling-Number of Beolroornt. 5 2 Subdivision Name <br /> Block S <br /> ❑Public/Commercial-Describe Use y <br /> ❑City of <br /> ❑Stotc Owned-Describe Use CSM Number 0 Vitiate of <br /> • Proposed K Td"m or Springdale <br /> III.Type of Permit: (Check:_my one bas on Hoek Complete line B if applicable) <br /> A. <br /> ®New System 0 Replacement System "❑TreatmenUHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> e• ❑Permit Renerval ❑Piemit Revision ❑Change of Plumber ❑Pail Transfer to New List <br /> Previous Pe mit Number and pate Issued <br /> Before Expiration Owner <br /> I V.Type of POWTS System/Component/Device: (Check till that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 Al-Grade ®Mound>24 in.ofsuitnble sail 0 Mound<24 in.ofnuimhle sak. <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreetment Devine WTI*) <br /> V.Dispersnl(freatment Aren Information: <br /> Design Plow(gpd) Design Soil Application Rote(gpdsl) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 750 1.0 750 750 99.2' <br /> VI.Tank Info Copeck).in Tata) Sof Manufacturer <br /> Gallons Gallons Units <br /> Nen Tanks Eiinin0 Tanks r51:; - w <br /> r=cf. N 3 rn i O s <br /> Septic orltatd,ng Tank 1600 1600 1 Dalmaray x <br /> Dosing Chamber 750 750 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility fur Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur - NIP/MPRS Number Business Phone Number <br /> .1-`1"/.0.10‘y I -T e(le._ ,-)7'.-'• a,/75 5 6'6b'.,g1-5-2e16.6 <br /> Plumber's Address(Such,City,Stare,Zip Code) // <br /> 135 0 Fr t 72_ d;R , V L'r c v Q t lh..J.-1 S3 5 <br /> VIII.County/Department Use Only <br /> PermitFeeDate Issued <br /> 'Approved ❑Disapproved s13b9/ (� �! �q�An�, �//�� An4/telig <br /> '❑Owner Given Reason for Denial V/I it I'l0�(1 1/4r Y1 ) <br /> IX.Conditions of Approval/Reasons for Disnoorovel M'LV / - <br /> Protect&Maintain:14 Mound/❑ At-Grade site and 15 feet downstopelri its natural <br /> condition. No compaction, excavation, disturbance,or vehicular traffic allowed. <br /> Attach to rernplele plans far the nzteer and submit in rhe County only on pow net Mss than A In s I I Inches In siz � I�� '(!i--'co <br /> _... aC `C7 �i•%tet ' <br /> insure tank locations are within 150'to all-weather service pad and within 15°vertical depth <br /> difference to all-weather service pad-Specific servicina mechanics must be provided if exceeded:` JUN 11 2021 <br /> L✓{tit17tA ewll LDf til LS ctSxit in Avl[� �lofres <br /> dJ innI HealthC"fB(¢ 41/41 �(11tC v-ee k adison&Dae County y <br /> win rted (41.Y44 <br /> r34Sir,/"( <br />