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eommeree.wi.gov Safety and Buildings Division County <br /> 201 \V.Washington Ave.,P.O.Box 7162 DANE <br /> isc o n s i n Madison, 53707-7162 Sanitary Permit Number�(o be filled in by Co.) <br /> Department of Commerce 57 8c9 V J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate:ovemmentai <br /> unit is required prior to obtaining a sanitary permit. Note: Ap I' Lion-IIR ...or sta e-o%• .'""-Ye Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal inf m n you provide may be used for secoi.. <br /> purposes in accordance with the Privacy Law,s.15 044(m,Siotats. <br /> I. Application Information-Please Print it Information <br /> Property Owner's Name steel# <br /> KONSTANTIN MARGOVSKY • • 0510-302-8710-9 <br /> Property Owner's Mailing Address �, Property Location <br /> 310 COUNTY ROAD MM 00 <br /> Govt.Lot <br /> City,State ip ode Phone Number NW Vi. NW '4, Section 30 <br /> BROOKLYN,WI 53521 -...-60 - 5-1732 (circle one) <br /> T 05 N; R 10 en-W <br /> II.Type of Building(check all that apply) Lot# <br /> ®I or 2 Family Dwelling-Number of Bedrooms, 3 Subdivision Name <br /> Block If <br /> 0 Public/Commercial-Describe Use City of <br /> State Owned-Describe Use CSM Number Village of <br /> Town of RUTLAND <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. 0 New System p Replacement System ®Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> NEW TREATMENT TANKS AT NEW LOCATION <br /> B. Chan List Previous Permit Number and D le Issued <br /> ❑ Permit Renewal ❑ Permit Revision gb of Plumber ❑Permit Transfer to New 1 •7i /('4f ?2 Before Expiration Owner `( J <br /> IV.Type of POWTS System/Component/Device: (Check all thud apply) <br /> ®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 ❑Other Dispersal Component(explain) Ei Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> +1-.4.0 A 1272 EXISTING 99.33 FT L.D.ENTERING BED <br /> VI.Tank Info Capacity in Total if of Manufacturer S <br /> Gallons Gallons Units P U d <br /> New Tanis Existing Tanks '"c, g . 4 ed <br /> }; '1 <br /> tt U ui rn w 6 n. <br /> Septic or Holding Tank t ro a 1500 1 -I` ' 'n d. 7''Y'4.S X <br /> Dosing chamber/ 0 1 �' 13V 1 4-k� �v1 d"c 're ej X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu r2.�SignatJ�e A. MP/MPRS Number Business Phone Number <br /> VERN HALVERSON - ._ _ _ - 227661 608-753-2462 <br /> Plumber's Address(Street,City,State,Zip Code) ‘ '9-S7V-35 0-eePe <br /> 8149 SWEENEY ROAD,BARNEVELD,WI 53507 <br /> VIII.County/Department Use Only <br /> Approved Disapproved Permit Fee �D•-atte Issued Issti j� Signa y Owner Given Reason for Denial $ 3.D' al�/� ''''y ∎∎:��',��_ e ,5. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to a Washes inches in size <br /> p$ - 1 (0532_ <br /> ChK- 49P-{3(0 t A03.°° ) 4gg37 $ +l1-°° 303,°°177ivK <br /> SBD-6398(R.02/09)Valid thru 02/11 / 7, �d um4 - <br /> 20, <br />