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`F►� Safety and BWIdIn Division County Dane <br /> fifWA,. <br /> ,a 4y, xgii 201 W.Washington Ave.,P.O.Box 7162 Smiley Permit Number(to be glkd h by Ca) <br /> . i' Madsen,WI 53707-7162 I J 201 6J cMo` <br /> Wl2 <br /> Sanitary Permit Application Slott Trauma=Number <br /> In accordance with SPS 31311(2).Win Adm.Cod&subm lion of this Santa the uppmptiate govaamadd onk <br /> is required prior to obtains a swag parole.Note Application forms forMale•owned POWTS ere submitted to Pmjea Addres(if Mama then moiling addicts) <br /> Its Oepummo of Slay sod Professional Sark&Personal isthmian you provide soy be reed for secondary <br /> proposes in madam wkk the Privacy Law,s.I3.01(1)(m),Suss. Crestwood Drive <br /> I.Application Infarmafoa-Please Print AS lagrrmation <br /> Property Owner's Name Parcel I <br /> Jay&Bonnie Gould <br /> 0509-072-8530-9 <br /> Property Owner's M uBng Addry Properly Locator* <br /> 807 Whispering Oaks Road Gorr La <br /> Ciity,State Zip Cede Phone Number $W X NW v..section 7 <br /> Oregon,WI _ 5 ( O°b <br /> lL Type ofBMBtang(dmektl1 that a', lots 7 5 N R 9 EerW <br /> 1ior2 Family Dwelling-Mather of: 4 3 Subdivision Name <br /> Block a <br /> • <br /> ❑Public/Commercial-Denulx � _ — _. ❑Cityor <br /> ❑Slate Ownd-DescrtheUse <br /> �'[ CShlNomber ❑VilhKeof <br /> MAY 18 20i 6989 m Tows of Oregon <br /> ill.Type of Permit(Cheek only one bantam line A.Complete We lit If applicable) <br /> A- ®New System ❑leimporkillpeseta 5CalM° aTank Replemamt only ❑Other ModffiatIon to brisling Sri=(wWa) <br /> B. ❑Permit Renewal ❑Permit Revision ❑tlrgr of Pbier ❑Powell Toweferto New La Pfe'aiO Paadt Number sod Data Issued <br /> Befare&piano• Owner <br /> IV.Type of POWTS System/Component/Deviee (Cheek all that apply) <br /> ❑Non•Pbsiaed IwQmtnd ❑Pssatsd In-Ground ❑At-Grade 0 Mound>24 is of alkabl soil ❑Monad<24 la.amiable sell <br /> ❑Bobbie Took ❑Oder Disposal Component(esphin) ❑Pretreemen Device(arphini <br /> V.DlspersaVTreatmmt Area Infernal/ow <br /> D esign Flow(aid) Design Soil Application RMdllpdsu Dlryeml Arm Re ain:d ai) Dhpernal Area Proposed Id) System Eland= <br /> 600 1.0 / D.S 600 j IZoo 600/ ICJ2 87.9' <br /> VI.Tank lore Cipae k' Total Units M�� <br /> u <br /> Neer Tots �Tack+ I 1 <br /> u m o &3 s <br /> snub moms'Trk 1000/300 — 1300 1 Dalmaray x <br /> beam cu.*. 750 _ 750 1 Dalmaray _ x <br /> VIL Responsibility Statement-1,the mama rospmBdlity for Installation of the POWTS shaven on the attached on <br /> Pho ber's Nos(Print) Plumber's Simonet MPMPRS Number Diatom Phone Number <br /> T:tarsC,-\-' .. Je\le r,r.,Ji.t)y,e as75l5 Cog145-7 tL <br /> Plumber's Addles(Suem,rilY.See.Zip Coda) <br /> • I'33o t=om: N--r— 0.d Vt-rcnva i W. _ -'� <br /> VIII.County/Department Use Only <br /> Ximmened ❑Dimpproved Perish lye _ Duo head hai t Agora � <br /> ❑Owner Given Reason br Oadd a 1,24„-. S- 2e/6 /f���� J < A ^"" <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P 1 - /ivotip f yrTEP1 ..117-- A- i - S 7 f . .lose - <br /> Fv - ccrc c 4 -z t, r -c yap ieley Ave a J' Ffecc.44,e Tigl�4� <br /> Ammo to amPkle ohms for the solos ad Montt to lee Canty a*ea paper tat Ion Ilea t leas It duds I eke <br /> SBD-6398(R.I1/l l) <br />