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• Aug. 31. 2009 10, 57AM, LE C E r e- 1� 1 No. 1235 P. 1 <br /> itii, commerce. rrp Safety an. u 1 lugs Division County <br /> { q 201 W.Wnshit t, n vc.-P.Q.Box 7162 Dane <br /> iscon ",1 AU'e 2 7 i diso , 53707-7162 Sanity (1 fi ,!�!�! <br /> department of Co me a •/ <br /> San Lary 'OH�".%,,�,'t- : i� SlateTranseetionNutnbcr <br /> ht accord,uec with s.Comm.83.21 - , 1 IIA'i 0 -f..s %Ili,: tilt form In le appropriate governmental <br /> unit is required prior to obtaining a snnilnry permit. Note: Application hints or state-owned POWIS are Project Address(if different than mailing address) <br /> submitted Id the Department of Commerce. Personal information yon provide may be used for secondary <br /> purposes in accordance with the Privacy Law,S.15.0,1(1)(m),Slats. 1175 Dunkirk Avenue <br /> I. Application Information—Please Print MI Information <br /> Property Owner's Name Parcel II <br /> Sarah &Christopher Bukrey 0511-093-8650-4 <br /> Properly Owner's Mailing Address Property Location <br /> 1175 Dunkirk Avenue <br /> Govt,l,ot <br /> City.Slate Zip Code Phone Number NW SW v 9 <br /> %,, ., Sce(ipu <br /> Stoughton,WI 53589 205-9866 (circle one) <br /> T 5 N. R 11 E or W <br /> II.Type of Building(check all that apply) Lot a — <br /> 6 t or 2 Family Dwelling—Number of Bedrooms, <br /> 3 — $ubditisinn Natle <br /> stock a Metes&Bounds Parcel <br /> ❑Pnblie/Commercial—Describe Use <br /> 0 City of _ --- <br /> 0 Slate()wiled—Describe Usc <br /> (SKI Number 0 Village of <br /> 81 Town of Dunkirk <br /> IiI.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Q]RCplacclncnt System ❑l'renlntenUl loldiug Tank Replacement Only ❑Oilier Modification to Existing System(explain) <br /> U. ❑Permit Reneunl ❑Permit Revision 0 Change of Plumber 0 Pennit Transfer to New t-ts1 Previous Permit Numlxr and Date issued <br /> ncfnrc Expiration Owner <br /> ^ <br /> 1V.Type of POWI-S SyslenifComponent/Device: (Check all that apply) <br /> M Non-Pressurized In-Ground O Pressurized In-Ground 0 At-Grade 0 Mound?24 in"of suitable soil ❑Mound<2-I in.°I-suitable soil <br /> ❑ilnldine Tani; ❑Oilier Dispersal Component(explain) ❑Pretreatment Device(explain) .. _ <br /> V.Dispersal/)-realment Area Information: <br /> Design Plow tgpd) Design Soil Application Rale(gpdmC ' Dispersal Area Required(se) Dispersal Alta Prnpnsed Isl) System Elevation <br /> 450 01 643 650 93,7' <br /> VI.Tank Info Capacity in Total ti of Manufacturer <br /> Gallons Gallons Units v t o <br /> New Tanks Existing Tanks 1 e, ° 1 <br /> Z.6 to 4 is o 2 <br /> septic or Holding Twil: 1600 1600 1 Dalmaray(1000/600) x _ <br /> nosing CInmI.cr <br /> VII.Responsibility Statement-1,the unrleraigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber-s Name(Print) Plumber's Signature 11iPTtPRS Number Business Phone Number <br /> MitUle• i5 CIA in a-44.4/1 -r. a32'(n AO!) g13-sobs <br /> Plumbers Address(Street,City,Stale,Zip Code) <br /> I1 a- fA.fc, Rao-d 6381 -t1 , cvf vk i W( 53581 <br /> VIII.CountylDrparlmcul Use Only _ _, <br /> pp/govt.(' ❑Uisnpprrned <br /> refill Pee Date Issue IssuingAgent�Signa / <br /> Fra ❑Owner Given Reason for Denial s 3 7 B/ I 09, / / r t - <br /> Ii.Conditions of Approval/Reasons for i pproval <br /> M a.X tRhti lM•ti ( � 1 w i-7. -x L S S • G Sp.-. <br /> ��y hilach In complete plans For the system and'Omit In the County only on parer not lava than H In x Mochas inches In slat <br /> aaa9 <br /> — 51 61 13 <br /> SflT)-6398(R.021(19)Valid Milt OZ/l l <br />