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Sep, 9. 2009 1 ; 59PM I)r— ?1�7 No. 1299 P. 1 <br /> • i. <br /> , cot17t71e1'Ce.wl. o Safr,�,�d Bu 11I Division County <br /> AUG 201 i.1.4 '.'igto • P.O.Bost 7162 ° Dane <br /> D.�ri n t - n4rlai,nn.w 1' —7162 11634r..A 0 <br /> Department of comma co <br /> C � ' a iI <br /> Sanita !e r .— r r f? ,.;e -...r‘.%,e o' . p Stott ransaction Number <br /> In accordance with s.Cnmm,1 121(21,Wi5 Adm,Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note. Application fonts for stare•mvncd POWTS arc Protect Address(if different than mailing address) <br /> submitted to The Department of Commerce. personal information you provide may be used For secondary <br /> purposes in accordance.with the Prig acy Lath,s. 1 s.oa(1 Zm),Slats,_-_-- Hwy 138 <br /> I. A.,lication information—Please Print Al!Information <br /> Property Owner's Name Parcel N <br /> Les&Kathleen Swanson 0510-082-8500-0 <br /> Property Owner's Mailing Address Property Location <br /> 1022 S, Perry Parkway Crovt,Lot <br /> City,State Phone Number NW % NW 8 <br /> Oregon,WI ��, r., Section <br /> , '_ 5 (circle one) <br /> I1-Type of Building(check all that apply Lot ti T N: R 1 E or W <br /> El 1 or 2 Family Dwelling—Number of Bedroo Subdivision Name <br /> Block* 23.6 Acre Parcel <br /> ❑Public/commercial—Describe Use ❑City of <br /> E3 State(mined—Dcseribe Use CSM Number ❑ Village of <br /> M Town of Rutland <br /> III.Type of Permit (Check only one box on line A- Complete line B if applicable) <br /> III n New System ❑Replacement System 0 TreattnenVFlolding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Now List Previous Permit Number end Date issued <br /> Beftre Expiration Owner <br /> 1V.T i, of POWTS S tem/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized 1n-Ground ]Pressurized In-Ground ❑At-Grade ❑Mound L.24 in of suitable soil ❑Mound a 24 in.of suitable soil Y <br /> ❑Holding Tank ❑Other Dispersal ersal Component(explain), - Pretreatment Device(explain) Multi-Flow FTB 0.5 ✓/ <br /> V.U••. rsal/i'rcatprent Area!Information: <br /> Design glow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sO System Elevation <br /> 450 0.6 750 1125 102.8, 103,1, 103.4, 103.7 <br /> Vi.Tank Info Capacity in Total #of Manufacturer •Gallons Ga1lon5 Units c a 2 <br /> _ <br /> New Taekx En Ring Tankt u <br /> s,u n 7 n r•+-(.7 e. <br /> Septic or Holding Truk 1000 1000 1 IDalmaray x <br /> t)Oain�r Ci.nnber 600 -�" <br /> 600 1 Da maray <br /> VII.Responsibility Statement-1,ti•e uwderxigned,amine responsibility for irafellation of the'POWYS shown on the attached plans. <br /> - Plumber-5 Name(Print) Plum i is Signature _ MPQv[PR. umber Business Phone Number <br /> M arrk 12.v s t•I Q�4.444 �` a-51-1 tolls) $75—5.0tog <br /> Plumbers Addrm(Street.City,State.Zip C.. Me— <br /> 913 t."1:0 1C, tom. (38, 5tD i;1111714 a Lk)I. 53SS1 <br /> VIIi.County/Department Use Only <br /> Permit Dec bate Issued issuing a 4, /h ,.r \eel ❑Disapproved <br /> ❑Owner Given Reason for Denial 1 623• 0 Qf I01 J <br /> IX.Conditions of Approval/Reasons for Disapproval j/ <br /> A tench lo compkte Mom for the ny.tem rand n.ba4t to dot Cauafy only as pepct aor Icr,.n..In 81/5511 inelree is slit <br /> D6- 111 <br /> ch -5,1+31f A(43eOO <br /> S(3i)-6198(R.(2!O9)Valid(Ifni 0111 <br /> eh1(-5153a $145:°6 <br />