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Y i . , <br /> 1.7 rommerce.w.(yov Safety and Buildings Division Cott <br /> 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> s co n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Cortarroro. 678/76 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Mm.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 thenmailing 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,a.15.04(1Xm),Stars. 608 CTH MM <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel A <br /> Michael&Laur11111.1 0510-192-8730-0 <br /> Property Owner's Mailing Address Property Location <br /> 731 Edenberry Lane (lei Lot <br /> City,State Zip Code Phone Number NW 'ti, NW x,section 19 <br /> Oregon,WI 53575 835-6505 T 5 N, R I O(circle one)o W <br /> II.Type of Building(check all that apply) Lot if <br /> 61 I or 2 Family Dwelling-Number of Bedrooms 4 2 Subdivision Name <br /> Block I <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 11905 CI Town or Rutland <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. l New System ❑Replacement System ❑TreatmauhloldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Preview Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑Prestuized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 is of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 0.4 1500 1512 98.0,98.5,99.0' <br /> VI.Tank Info Capacity in Total I of Manufacturer g <br /> Gallons Gallons Units 1 0 S i New Taub Ps$tle Tanks m <br /> rn 1,, 1 i4 <br /> - <br /> Septic or Holding Teak 1250 1250 1 Crest x <br /> Dosing Clamber 750 750 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for listal(atlen of the POWTS shows on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 11BWMPRS Number Business Phone Number <br /> ocher: 1 U en-s d f lee-40-1Z'fie 4,24 '-1- e. 61 3s-7&3/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 5,L 3 Li-k CC)/h /fee' G'G'e fvG7 wvr .5-3__C ---j oanty/Department Use Only <br /> ved ❑Disapproved Permit Fee Date Issued la iiii❑Owner Give Reason for Denial 5 331- ` /0)/3/0Y , `1,; II <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> �Amisch to complete plans for the system sod submit to the Comfy only in paper sin bar thou 510 111 Inches I.due <br /> SBD-6398(R.01/07)Valid thry 01/09 <br /> c:11K .- L+ 5-7_3-2- 77— <br />