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Sep. 10. 2009 1 . 54Pv'' !L U 1s `fl No. 1303 P. 1/2 <br /> .� .,, <br /> commerce.9 ••ov , <br /> tv a t dings Division County <br /> '! 1' SE n 3912 I 'ash • r v e.P.O.Box 7162 ry Dane <br /> DQ �� Madi. n. { 53707-7162 Sa t A <br /> Department of • me • _ • <br /> • • • I t i <br /> San ' a : State Transaction Number <br /> In acco*dance with s.Comm.83.21(2).Wis.Adm.Code.submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanibry• permit. Note: Application forms for sttrle•o'vned POWTS arc Project Address(if different than tnailingaddress) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privaey:Law.s. 15.04(I)(m).Stats, 1956 Koshkonong Road <br /> I. Application Information—Please print All Information <br /> Property Owner's Name - Parcel P <br /> Gerald&Ann Anderson 0611-141-8521-9 <br /> Property Owner's Mailing Address Property Location <br /> 516 S.Van Buren <br /> Govt.Lot <br /> City,State Phone Number NW y,• NE v.. Section 14 <br /> Stoughton,WI 5 (circle one) <br /> II.Type of Building(check all that app Lot p T 6 N: R 11 E of W <br /> EI I or 2 Family Dwelling-Number of Bedtoems 3 Subdivision Name <br /> \,........._.) <br /> Block 15 Acre Parcel <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑Slate Owned-Describe Ctse CSM Number ❑ Village of <br /> 1 Town of Pleasant Springs <br /> III.Type of Permit_ (Check only one box on Tine A. Complete line B if applicable) <br /> A. ❑New System n Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision ❑Change of Plumber l ❑Permit Transfer to New [•ist Previous Permit Number and Date tssucd <br /> Before F.xpiral tort Owner <br /> IV.Type of POWTS System/Component/Device:,Check all that app!)) <br /> 1E Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At•Grade 0 Mound 24 in.of suitable soil 0 Mound a 24 in.ofsuitable soil <br /> ❑Holding Teak ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.bis. mat/Treatment Area Information: <br /> Design Flaw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s() Dispersal Area Proposed(sl) System Elevation <br /> 450 0.4 1125 1134 98.0' <br /> VI.Tank ink Capacity in Total i of Manufacturer <br /> Gallons Gallons Ltnits 3-.) o u <br /> v 6 <br /> New 7utk< l:Nisling Tenks ZE u g a '' <br /> -. <br /> i U n n i:= 7 <br /> semis or Naldinc'ank 1300 1300 1 Dalmaray(1000/300)[x <br /> •.DNCinp Cltamhcr - -' -- I <br /> VB.Responsibility Statement-I,the■adcr*igaed,assume responsibility for installation of the POWTS she the attached plans <br /> Plumber's Name(Print) Plumber's Signature iggi umber Business Phone Number <br /> AI c c.. Kt)SefAkt CLAIM, i/ 'X.Agef a 3 a.{2-$ ( o 8,) $r13 `50(o g <br /> Plumber's Address(Street.City.State,Zip Code) <br /> 99 a- S it, I .t 138, u-syk-ton,. sal 5a5sc <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee q Issued issuing A - t Signature <br /> 0 Owner Olson Reason for Denial $n4 F.,.-- `I 1s 1 a` ` i <br /> I1t-Conditions of ApprovaURca54nS for iRappraval <br /> it <br /> Y1•4,c -c l5� G 6r. 40 <br /> Attach to complete ohm For the system and vomit to the County only on paper not WIN than S 1R a I1;00.42 ro Aft <br /> Ds- qs04 <br /> CYli<- 52 % <br /> S131)-63911 IR.02/09)Valid ten,D2/11 <br />