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V1l <br /> t \J L u L I ,i <br /> • t 2 2008 <br /> �, <br /> t:ommerce.itd.gov Safety ant A�jldings Division County <br /> „ F blic 12 1aViiV1s)�igton Ave.,P.O.Box 7162 Dane <br /> Departme IS�Q�S'n Env ronm."'':`'I►I � 5370''--7162 Sanitary PermitNumber(tobefillediinbyCt.) <br /> mt� �. 5181101 <br /> Sanitary Permit Application SateT"`�et;°"N"mber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is requited prior to obtaining a sanitary permit. Note: Application Corn for state-owned POWTS are Project Address(if different thenmeilingaddress) <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),Stats. 7615 Rauls Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel A <br /> Dan Kruchten,Kari Hellenbrand 0808-052-8500-5 <br /> Property Owner's Mailing Address Property Location <br /> 7615 Rauls Road <br /> Govt.Lot <br /> City,sate Zip Code Phone Number NW 'A NW '/.,Section 5 <br /> Dane,WI 53529 (circle one) <br /> II.Type of Building(check all that apply) Lot 0 T 8 N; R 8 E or W <br /> g I or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block 0 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 3187 D Town of Springfield <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) . <br /> A' ❑New System ❑Replacement System 13 TteatmentMoldingTank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Prev 1O1tl Permit Number and Dab Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) <br /> fil Non-Pressurized In-Ground ❑Pressurized In-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.DispersaVl'reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.4 1125 1128 Exist. 87.2',88.6' <br /> VI.Tank Info Capacity in Total I of Manufacturer <br /> Gallon Gallons Units i - 3 v <br /> New Tanks Exbtiog Tanks 'p 8 1`3`. i <br /> &cg v7 en I:t w <br /> Septic or Holding Teak 1000 1000 2000 2 Wieser x <br /> Dates aerobe, <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation raf the FONTS shown on the attached pleas. <br /> Plumber's Name(Print) Plumber's Signs MP/MPRS Number Business Phone Number <br /> Chris L1 e-r (O — 6,41 _ 1,01-61164C3/ <br /> Plumber's A ess(Street,City.State,Zip Code) <br /> Yea\Mtn .a Ileicums5 S-t Pr Bose lit& 541/x-C ll) w) 5135T3 <br /> VIII.County/Departument Use Only _ <br /> Approved ❑Disapproved Permit Fee Dlate issued tins Signature <br /> ❑Owner Given Reason for Denial $Z 78.OQ /O—/,D8,, pK,� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> _„....G- fix..- -6-e x2.-, ,,,-'• - , <br /> Attach I.complete plain for the system aid submit M the County any an paper ea let Mex$M x II lecher 1.size <br /> D5- Si/8o elk- 4!519 <br /> ,c <br /> E,ROYAL, DANE COUNTY <br /> SBD-6398(R.01/07)Valid than Ol/09 ._,,,,...f:7,-.::,....L CtJCS ;^T H,) D ITo-` <br /> ,. iN PLANS OR SPI=CIFIC;�- <br /> �, L i SjJNS, LMMINA7 ON OVER <br /> Tit-)tI OR��,NY DAMAuc THAT MAC: <br /> ` -' `Jf,�," ,C=R It`JSTALLA.TjON ANu nESERVE <br /> r, h`* l.O ORDER CHANGES OR ADDITIONS <br /> SHOULD CONDITIONS ARISE MAKING THIS <br /> NECESSARY <br />