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'2'.--- 1.Th FLE-,- ‘,7 ,=.--', Vi F "'N <br /> commerce.wl, L UL 1 4Sakijkjid Btuld-ag Division ' County <br /> 201 W.Washington AP.O.Box 7162 Dane <br /> ta.s c o n s I p_-_____..-_ Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Deportment ofCo era Public rieaith MDC 51 S O(A <br /> Sarni lvirol ' . State <br /> e,Transaction Numbeerty <br /> In accordance with s.Comm.13.21(2),Wis.Adm.Code,submission of this form b the appropriate governmental .Y7Vr G ( - "f JJ m l t l <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different thanmailaig eddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> Pigmies in acoordarece with the Privacy Law,s.IS.04(IXm),Slats. 609 Craig Road <br /> L Application Information-Please Print All Information _ <br /> Property Owner's Parcel 0 <br /> Tim&Er 0512-152-8400-2 <br /> Property Owner's Mailing Address Property Location <br /> 690 Craig Road <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE Y., NW 'A,Section 15 <br /> Edgerton,WI ; 534 290-5661 (circle one) <br /> H.Type of Building(check all that apply Lot 0 T 5 N; R 12 E o W <br /> ®I or2 Family Dwelling-Nwnberof 5 1 Subdivision Name <br /> Block P <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 7623 I2 Town of Albion <br /> HI.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. ❑New System a Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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-Grand ❑Pressurized hi-Ground ❑At-Grade ii Mound>24 in.of suitable soil ❑Mound<24 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Cgnponent(explain) ❑Pretreatment Device(explain) <br /> V.DispersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> 750 1.0 750 752 99.5' <br /> VI.Tank Info Capacity in Total d of Manufacturer <br /> Gallons Gallons Units .1 tg ts <br /> New Taub Existing Tasks I 3 gi <br /> SepdcerHeldtagTank 1600 ! 1600 1 Dalmaray x <br /> L <br /> Dosing Chamber 750 750 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersigned,assume respouslbllity for isstallatles of the POWTS thews on the attached plans. <br /> Plumber's Name(Print) Plumber's Si atone MP�1PR)lumber Business Phone Number <br /> Mc rk. RA).5e41L�4.t Adel �` OV 3�1 a4 (08) 8'73 -506S <br /> Plumber's Address(Street,City,State,Zip Code <br /> 't1 - Hwy. 131? St)wart, 5t'ow.iftft l 1 (OT 55581 <br /> VIII.County/Department Use Only <br /> Permit Fee Date h su ed <br /> Jik/pproved Disapproved , Iss u xj214,r.... <br /> ❑Owner Give Reason for Denial S rm //t //O e <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> rc-c ,D,t, • I,' /11 FA, T P(-4v <br /> Attach to complete plans for the system nod submit to the County only en paper net leis than s tel it tl inches is size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />