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r/� -; ' Safety and Buildings Division County Dane (" <br /> :T .1.' ,. 201 W.Washington Ave..P.O.Box 7162 Satdacy Permit Number(to be idled is by CO <br /> It 4 Madsen.WI 53707-7162 + <br /> i- --2C.I'TD—CCYY4=c1 <br /> Sanitary Permit Application State Tremont Number <br /> In accordance with SPS 31331(2).Wis.Adm.Cade mbmisbaaftis mum to theapptopriae govanosentel unit <br /> is raid prior to obaisetg a wintry prank-Nate:Apothegms Rams far sate-owned POW S=submitted to Project Add cos nrdtlkcm dem mailing address) <br /> the Department of Slay and Rainstorm(Sacks.Prnoosl I leorlton you provide mg be toed for seconds(' <br /> proposes it somrttmm with dm Privacy[tor.s.IS.W(I)(mt.thus. <br /> L Application Information-Please Print AB laformadsa <br /> Propoty Owner's Name Pavel It <br /> Mary Van Bemmel 0508-223-8600-3 <br /> Prapaty Owner's Wing Address Property spa <br /> 710 Schaefer Road <br /> Govt. <br /> City,Shoe Phone Number NW k, SW sr,Sawn 22 <br /> Belleville,WI _,53508 7 5 N g 8 ( own <br /> li.Type of Building(cheek all Not 1 Lot a <br /> Ku I se2Fmnrly Dwelling-Number of 3 Subdivision <br /> Btodc# Metes etes&&r B Bounds Parcel <br /> ❑Public/Commercial-Describe Use ❑City or <br /> ❑stste Owned-Describe Use CSIANumber D VRkgeaf <br /> ®Towe of Montrose <br /> III.Type of Penult(Cheek Daly one box on line A.Complete lise B If applicable) <br /> A. ❑New System DT Re iocenseat System ❑TtestsuarilHokhog lmmt Replacement Only ❑Other MoiUrsctlton to Entine System(explain) <br /> B. ❑Perm Renewal ❑Permit Revidm ❑f—m-or Plumber ❑Pamdt Tsmsoferto New lilt rieriws Paul'Namberaod Dale Iswed <br /> Before Expiation Owner <br /> IV.Type of POW fS Syseen0ComponeetlDeviec(Clock all that epptyW <br /> IN Nova to-Gourd D Pressurized la-Groad ❑At-ode ❑Moud>2a in.arsenide soa ❑Mond<24 in.ofsnasble soil <br /> . <br /> ❑Holding Tank ❑Other Disposal Component(esp(mt) ❑Peetrmbtod Device(explain <br /> V.DiSPersidirrestment Area Information: <br /> Design Flow(gat() Dwight soh Application Rate( W) Disposal Area Regai ndial) Dispersal Area Proposal(ii) System Ek.miam <br /> 450 0.4 1125 1128 98.5' <br /> VI.Tank Info Copedly in Told 9 of Mmanfaamer <br /> Gallons . Units 1$ v 1 <br /> NesTab I Tart Al !4 <br /> . nu 3 to e5 a <br /> Septc°.hitag7iok 1000 --- 1000 1 Crest x <br /> °vial Chamber 600 '' 600 1 Crest x <br /> VILRespoass'btityStatement-I,the me....∎,, re spensBsRky for hateRWksa f the PORTS show.oa the Maned pleas. <br /> Plumber's Name(Prim) .' '_... / MP/MPRS Number Buakesa Phone Number <br /> L. 0° af._� - `ter.. r� [�Q/ia,wyz '/ZV 3a'V <br /> Pterobes's Addtms(Shad,My,Slate,Zip Code) Relk.47� Arz "!5 u--- _________,.....\\ <br /> /U7b� Ct P _ <br /> VIII.Couaty/Dapartment Use Only <br /> Peat*Fee Danelsmd <br /> '<Apposed ❑Diseppoved <br /> 0 Owner Ginn Ream forDant s N._ 3_39 c -y <br /> - <br /> IX.Conditions of ApprovadReasws or Disapproval <br /> v---7�-- o if fop& Mk rr lc- P ty s ev E <br /> N <br /> Atsadu Is erppkk alas for Or giber awl sauna to the Cooly age as mental his tom 1 to s II WaehorL she <br /> SBD-6398(R.I 1/I1) <br />