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„ Industry Services Division County //p Y� 4822 Madison Yards Way Dane fV j 1`i a p �, Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) \,` ` S../s/-1 P.O.Box 7162 l ,�_ . Madison,WI 53707-7162 )0 A d — 003 Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Services.Personal information you provide may be used for secondary 3313 Nelson Road purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I.Application Information-Please Print All Information Property Owner's Name Parcel# Bretni Anderson 0810-243-0120-0 Property Owner's Mailing Address Property Location 7141 Kalland Way Govt.Lot City,State Zip Code Phone Number Sun Prairie, WI 53590 NE % SW 'A, Section 24 H.Type of Building(check all that apply) Lot# T 8 N R 10 Qor W Igi1 or 2 Family Dwelling-Number ofBedrooms 4 2 Subdivision Name Block# ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of 15978 is Town of Burke III.Type of POWTS Permit:(Check either"New”or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if applicable.) A. New System �c lacement System Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) ) B' ❑Holding Tank 1151 In-Ground 'TIM-Grade Mound ❑Individual Site Design IIOther Type(explain) (conventional) If—' C. 1:1 Renewal Before ❑Revision ❑Change of Plumber [Transfer to New Owner List Previous Permit Number and Date Issued Expiration IV.Dispersal/Treatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 600 0.4 1500 1500 EISA 93.7' Capacity in Total #of Manufacturer II Tank Information Gallons Gallons Units n v o y o New Tanks Existing Tanks - - e e, 0 cU rn ' v, wU P. Septic or Holding Tank 1250 1250 1 Crest I I I I I I I I Dosing Chamber 750 750 1 Crest I ✓ I = V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number 11 Plumber' Address(Street,City,State,Zip Code) 335Y P-- s Ak://4.Kj i,...); 5-35:15 VI.County/Department Use Only Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Si re ❑Owner Given Reason for Denial $ `I(7 ii. 12/30/2022 Conditions of Approval/Reasons for Disapproval a ,lie There are two existing private septic systems on the property. The two existing systems must be properly abandoned by the time of inspection. See attached CSM for locations of existing POWTS. Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 11 inches in size SBD-6398(R.03/21)