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-.41' 'i co., <br /> '1:LN. <br /> / f 4.,,,,_ Safety and Bullrings Division Dane <br /> B''":iii 4 201 W.Washington Ave..P.O.Box 7162 Smmitmy Permit Number(to be filled in by <br /> S P s Madison,WI 53707-7162 <br /> 1 3-26 (0--M 81 <br /> Sanitary Permit Application State TmnseaimtNumber <br /> Is accordance with SPS 38121(2),Wis.Adm.Code,submission of this form to the appropriate governutentel unit <br /> is required prior to obtaining a sanitary penm'L Note Application forms for stale-owned POWTS ere submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Sen•kc Personal information you provide may be used for secondary <br /> pmposes'in accordance with the Privacy Law,s.IS.04(lXm),Slats. Pierceville Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Nome Pastel it <br /> Joseph Kaltenberg 0811-341-9310-0 <br /> Property Owner's Mailing Address Properly Location <br /> 4989 County Highway TT Gust to <br /> City,State Zip Code Phone Number SW b, NE 74.Section 34 <br /> Cottage Grove,WI 53527 608-837-8044 (circle one) <br /> 11.Type of Building(check all x that apply) Lot T 8 N; R 11 E or W <br /> ®I or 2 Family Dwelling-Number of Bedrooms 4 1 Subdivision Name <br /> ❑Public/Commercial-DesrriRsE C E I Y E D Biodt x ❑City or • <br /> ❑rime Owned-Desenbe Use JUN S 2 2016 CSM Number ❑Village of <br /> tLgNLpeGC 14186 ®Town of Sun Prairie <br /> III.Type of Permit: (Chee d g(rgE_Cpasplete line B if applicable) <br /> A' ®New System ❑ eneM System 1 w❑0 TrreemrmenrMo Tunic R Only <br /> yes Rgdae ysl lding eploccmem ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Ch of Plumber ❑Permit Transfer .New seer Previous Permit Numbs and Date Issued <br /> Before Expiration Owner <br /> 1V.Type of POWYS System/Component/Deviee: (Check all that apply) <br /> ®Non-Pressurised In-Ground ❑Pressurised In-Ground ❑At-Grade ❑Moond>24 in.of suitable soil ❑Mound<24 in.of nibble soil <br /> ❑Holding Tads ❑Other Dispersal Component(espi in) ❑Pretreatment Devi=(explain) <br /> V.DispersaVTreatnsent Area Information: <br /> Design Flow(gpd) Design Soil Application Rmdgpdel) DIspersai Area Required(s0 Dispersal Area Proposed(sq System Elms:lion <br /> 600 0.4 1500 1512 95.7' <br /> VI.Tank Info Capacity in Total If of Manufacturer <br /> Gallons Gallons Units o u <br /> Nnr Tanks Existing Tanks yS ts i u <br /> ii:U is to g <br /> r_o E. <br /> Septic° Took 1250 1250 1 Crest x <br /> Dosing Clamber 750 750 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,ossu a responsibility for bundled=err the POWCS shown on the attached plans. <br /> PI 's Naoef(fPrim) P see MP/MPRS Number Business Phone Number <br /> I i+�(,,..,,rri - 11.1 (ey _ C6F'c7 7?.r%uS <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I(iP :at eye. , )u' (7,2. p., c" s'r-l'5. <br /> VIII.County/Department Use Only <br /> XAppmvcd ❑Disapproved Permit Fee Dale Issued Issuing C�/,/�,� <br /> ❑Owner Given Reason Fa Denial �' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete pleas for the system sad submit to the Comely inky as paper sat less than a Ills 11 Inches In sloe <br /> SBD-6398(R.I I/11) <br />