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• <br /> I <br /> 1.12 t c#a 0c,8*-f et* 3c,4'7 <br /> comm.it. '.a a gor • I 1':';ety a1 17,ings Division County <br /> 201 W.Was on ve.,P.O.Box 7162 Dane <br /> is co S f Madi - ■,WI .3707-7162 Sanitary Permit Number(to fit in by Co.) <br /> Dement• • .'ublic Health MDC ,x/80 9 p <br /> j .. s o_,t- Hea_ State Transaction Number J <br /> In accordance with s.Comm.13.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ."111Y%-- <br /> "4IY E /941/1-1. 2/212-_5-0 <br /> unit is requited prior to obtaining a sanitary permit. Note: Application fornr for state-owned POWTS are Project Address(if different thentnailing 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,B.15.04(1Xm),Stau. 1690 CTH B <br /> I. Application Information-Please Print MI Information <br /> Property Owner's Name Parcel N <br /> M&W Olson Partnership 0611-244-9015-6 <br /> Property Owner's Mailing Address Property Location <br /> 1690 County Highway B Govt.Lot <br /> City,State - Zip Code Phone Number SW v., SE v.,section 24 <br /> Stoughton,WI X3589 873-7562 (dick ) <br /> onee <br /> * T 6 N; R 11 Eo )W <br /> II.Type of Building(check all that a ly) <br /> (I 1 or 2 Family Dwelling-Number of Bedr 3 Subdivision Name <br /> Block N 37.5 Acre Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Et Town of Pleasant Springs <br /> M.Type of Permit: (Check only one box on line A. Complete tine B If applicable) <br /> A <br /> ❑New System ®Replacement Syst- Treatment/Holding Tank Replacement Only I Other Modification to Existing System(explain) <br /> 1 RE—CP c 7 Pvse 4.- TrY <br /> B. I 0 Permit Renewal ❑Permit Revision ❑Change of Pltrrrtber 0 Permit Transfer to New List Previous Permit umber and Date Issued <br /> f Before Expiration Owner 2' / (0-(9- ?8 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 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.DlspersaV[reatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.5 900 900 Existing 88.4',89.6' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units s Ai p <br /> New Tanks Existing Tanks "Y' H 'a <br /> S[g ill vn 1,!-A a <br /> Septic artiste*Tank 1250 — 1250 1 Crest(700/550) x <br /> Dosing Chunber I <br /> I i 1 i 1 !!!. <br /> I <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for lusaliatoa elate POWTS shown oa the attached pleas. <br /> PI�ger s Name(Print) <br /> Z„).22, k _�/�� / j ���‘ <br /> Plumber Address(Street,City,State.Zip Code) Sr �„ � �� /��/ <br /> v51,C. /X /r,,e ��� �� (.J! r <br /> VIII.County/Department Use Only L <br /> roved ❑Disapproved <br /> Permit Fee Date Issued Issuing A S ��`/`7 �j� <br /> ❑Owner Given Reason for Denial s 2 7e g-4-08 c t�v ,,, <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> -fEz= Psi �f' M� �t �61/ / <-/N <br /> --) `111-0- re,e t-v (j Fi'- fYE i XE/' ��/rtt 4,Vi2 <br /> iff — 02 cci"( E,c(f/ /c 44''Jq /' ,v c44/iv , <br /> Attach to complete plans for the system sod submit to the County only on paper sot Mss than s In s ft Inches Is she <br /> SBD-6395(R.01/07)Valid thru 01/09 <br />