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!(. 1..q _ <br /> i. <br /> 1: AUG 2 5 2008 ` - C i A e c k 219 y442.3.0 D61.19 2753& <br /> I Cosnmerce.wt,gav Safety and Bulling:Division t County <br /> p 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> i c/�O n c MAdison,WI 3707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> vv v iiii <br /> 57g la <br /> Sanitary Permit Application StaxTrsttaactionNtmrber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application force for stateowned POWTS are Project Address(if different thanmaiiing 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.13.04(1)(m),State. Schadel Road <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name 14 <br /> Steve&Linda LaRonge (n:24 0712-314-8003-3 <br /> Property Owner's Mailing Address Location <br /> 2821 Wentworth Drive <br /> Govt Lot <br /> City,State Zip Code Phone Number NE v., S E v.,section 31 <br /> Madison, WI 53719 347-0449 (circle one) <br /> II.Type of Building(check all that apply) ' Lot It T 7 N; R 12 E or W <br /> 011 or 2 Family Dwelling—Number of Bedrooms 4 2 Subdivision Name <br /> Block f <br /> 0 Public/Commercial—Describe Use <br /> 0 City of <br /> / 0 State Owned—Describe Use CSM Number ❑Village of <br /> 8390 O;Town of Deerfield <br /> j -ype of Pe , (Chet only one box on line A. Complete line B if applicable) <br /> A System Replacement System 0 Treatment/HoldingTank Replacement Only 0 Other Modification to Existing System(explain) <br /> New S erne •R laeement S em <br /> B. ■ Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner l <br /> IV.Type of POWTS System/Component/Device: (Cheek all that apply) ` <br /> OtNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 is of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaVlreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sI) Dispersal Area Proposed(si) System Elevation <br /> 600 0.4 1500 1620 _ 83.0,85.0,91.0' <br /> VI.Tank Info Capacity in Total I of Manufacturer <br /> Gallons Gallons Units vNewTmb Min Treks Fil !j k i 1 t. <br /> sCptIc Holding Tank 1650 1650 1 Meade(1000/650) x <br /> Datng Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for tistallatlon tithe POWIS shows on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature •ItBP/MPRS Number Business Phone Number <br /> A l-(sty W. Ww+01 Z w � 22016-5- _831-`3103 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (0S1-F.) 1/..14A.A.rkitku.. InA 597 <br /> VIII.Coanty/Department Use Only _ <br /> Permit Fee Date Issued Issuing A Signatur- �/ <br /> pproved 0 Disapproved ��� / / p� / <br /> 0 Owner Given Reason for Denial /R!�/zO / <br /> IX.Conditions ofApproval/Reasons for Disapproval /.. Y <br /> 1 <br /> Attack Is complete plea for the system aid submit to the County only ea paper not less than a 1r2 111 Inches I she <br /> SBD-6398(R.01/07)Valid tine 01/09 <br /> NOV - 6 2008 <br /> 1 <br />