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/1 6rJ <br /> ry ! <br /> L____ FEB F EB 6 2009 ' <br /> • corce.wl.gov , <br /> mme L.- - _.Safety and BnO+�.eQilins9 ivisiot County <br /> w 2( 1i117.iV1�ashhiitid i( P.O.Bork 7162 Dane <br /> Dseonsin Er1Vlr1.lik'S , illIi ,7 7147 t Sanitary Permit Number(to befilkdinbyCbJ <br /> D Deportment <br /> Sanitary Permit Application State Transacti umber (. <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Ili <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are • o'- A.. -.-• '■annnif g address) <br /> submitted to the Depanment of Commerce. Personal information you provide may be used for secondary cc <br /> purposes in accordance with the Privacy Law,a.15.04(1Xm),Stets. 6,0 o $TH MM <br /> I. Application Information-Please Print All Deformation <br /> Property Owner's Name • ' I N <br /> Jeffrey Friebert, Sally Kopecky •5 ■ - :700-0 <br /> Property Owner's Mailing Address Property Location <br /> 404 N. Main Street Govt.Lot <br /> City,State - Zip Code Phone Number NW Y., NW v.., section 19 <br /> Oregon,WI 53575 (circle one) <br /> T 5 N; R10 EorW <br /> II.Type of Building(check all that apply) Lot* <br /> GI Ior2 Family Dwelling-Number ofBedrooms 3 1 Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 11905 Gt Town of Rutland <br /> III.Type of Permit: (Check only one boa on line A. Complete line B If applicable) <br /> A 13 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ��rt ' List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal �t Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> _IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Q Non-Pressurized In-Ground ❑Pressurized h-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersallTreatment Area Information: <br /> Design Fiow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(af) Dispersal Area Proposed Of) System Elevation <br /> 450 0.4 1125 1125 98.5', 99.2', 100.0' <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units to <br /> New Tanks existing Tanks G y Y .y lZ a <br /> Septic er Holding Tank 1600 1600 1 Crest x <br /> 'Doting Chamber _ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for ltistaliation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si to 'IMPRS Number Business Phone Number <br /> Robe,T �v6v`Soh Plumber's <br /> iz/-6// (60S) S75-- 703/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> S.ot Inca/pf lid 6/'e ,H W, J35 7 <br /> VIII.Coanty/Department Use Only - <br /> pproved ❑Disapproved Permit Fee Dote sue Ins -.. t•�4` <br /> s '5 , <br /> ❑Owner Given Reason for Denial �/ O ����, `�I��L' <br /> IX.Conditions of Approval/Reasons for Disapproval / <br /> I--V{; i/�iT�1/1, i tw * ill <br /> Attach to complete plans for the system sad submit to the County only on paper not has than I in x II ladies is site <br /> SBD-6398(R.01/07)Valid thru 01/09 <br /> CK - LI -7 I4 -In _- <br />