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i ".., <br /> 'II E C TE 't1 VI E --,,s. <br /> ,........._____ _ _.. ._., <br /> 1 artti, <br /> commerce.wi.gov Safety and Buildings Division i 1 ,.. <br /> 201 W.Washington Ave.,P.O.Box Pr62— Dane <br /> it <br /> Isconsin Madison,WI 53707-7162 i L. _Sanitary PennitNtunber(tribe filled in by Co.) <br /> ,- <br /> Department of COrnInetten k .Lii!.... 5/8-. Q 4 <br /> 1 -57-iii•le-cii;' 'iacti:;,,14.4.42,-------' <br /> Sanitary Permit Application <br /> In accordance with s.Comm.83.21(2),Wie Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project 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 Privacy Law,s.15.04(iXm),Stets. 6)0 g CTH MM <br /> L Application Information-Please Print All Information <br /> Property Owners Name Parcel It <br /> Jeffrey Friebert, Sally Kopecky 0510-192-8700-0 <br /> Property Owner's Mailing Address Property Location <br /> 404 N. Main Street <br /> Govt Lot-City,State Zip Code Phone Number NW y., NW V.,section 19 <br /> Oregon,WI (circle one) <br /> T 5 N; R 10 E or W <br /> II.Type of Building(check all that appl . j Lot I <br /> GI I or 2 Family Dwelling-Number of Bedroc( Block 8 3 <br /> 1 Subdivision Name <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> 11905 131 Town of Rutland <br /> III.Type of Permit (Check only one box on line A. Complete line B If applicable) <br /> A- 13 New System D Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber ' 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 1 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersalareatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required($1) Dispersal Area Proposed(al) System Elevation <br /> 450 0.4 1125 1125 102.0' <br /> I VI.Tank Info Capacity in Total of Manufacturer _ <br /> Gallons Gallons Units i _ <br /> -0 <br /> ,. t ^ te <br /> New Tsob &Win Tanks tE t3 'EH b, ill I.. <br /> Septic or Holding Task 1000 1000 1 Crest x <br /> Doan Chamber 600 600 _ 1 Crest x <br /> VD.Responsibility Statement-I,the undersigned,assume responsibility for hirtaliation of the powrs Awn on the attached plant <br /> Plumber's Name(Print) Plumber's S*ature YiP/MPRS Number Business Phone Number <br /> 1506err 5t/-er-saii 72(.71-r-Ct/-e- 7-7 21.4 // - 4 M g 33--7627/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5„:2 A5- Li n e_p/fr, Rd <br /> &j-ef 4;.,Al //k"7 5-3 k 5- <br /> VIII.County/Department Use Only <br /> Permit Fee Date issued Lau; • .• ' . 1. <br /> .."%:.Approved 0 Disapproved <br /> s ..-0-4,7,--- 1 izia/62 de$4. .4 it.,, i <br /> o Chimer Given Reason for Denial I Nra-•_..k... <br /> is <br /> IX.Conditions of ApprovaUReatons for Disapproval <br /> Attach to complete pleas for the system sad submit to tbe County slily ea paper net lean them II 10 111 team la size <br /> 1>g''' (40 CP VO di K- q 70 73.77_-- <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />