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.. , Dic rr, cL-5• .; ,, __-.. /1/ _ __, <br /> , ,,, ,___ ,_ .....,, ,_,______ i Iti,, <br /> t:0171rr1e goy J V L 4 2USi`ety a dings Division County <br /> r� 201 W.Washat Ave.,P.O.Box 7162 Dane <br /> S COI rS <br /> Madison,WI 53707-7162 Sanitary Permit Number(to beflled' by Co.) <br /> Department U�IIC r r._'`�. :i[ -5, 60711 <br /> EtI ;irlfYl `fsj f 22 ;1 State Transaction Number <br /> Sanitary i>4 Pow 'GeY7 <br /> In accordance with s.Comm.13.21(2),Wis.Mm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit Note: Application forum for state-owned POINTS are Project Address(if different than mailing 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),Stets. 852 Collins Road <br /> L Application Information-Please Print All Information <br /> Property Ownei s.Name Parcel R <br /> Jeff Alme 0511-153-9500-0 <br /> Property Owner's Mailing Address Property Location <br /> 794 Collins Road <br /> Govt Lot <br /> City,State Zip Code Phone Number SE y., SW v.., Section 15 <br /> Stoughton,WI 53589 (circle one) <br /> II.Type of Building(check all that apply) Lot 4 T 5 N; R 11 E or W <br /> Q 1 or 2 Funnily Dwelling-Number of Subdivision Name <br /> Block 19.8 Acre Metes&Bounds Parcel <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> ®Town of Dunkirk <br /> III.Type of Permit: (Check only one box on line A. Complete tine B If applicable) <br /> A ❑New System E Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal 0 Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) . <br /> 0 Non-Pressurized In-Ground 13 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(af) Dispersal Area Proposed Of) System Elevation <br /> 450 0.4 1125 1128 97.0' <br /> VI.Tank Info Capacity in Total I of Manufacturer <br /> Gallons Gallons Units ,S i' u <br /> NewTanb Existin Tanks 3 <br /> a ktg yl y w1 a <br /> Septic or Holding Tank 1000 1000 1 Dalmaray x <br /> During Member 600 _ 600 1 _ Dalmaray x l <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Z 3 2i 8 a t�3-5-o G b/142 ,e0-4 4.-/)--/3/A,0-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 Z 4' c' /3 S'.r`,'‘,0e€,- --, faF-�. w, 5 7 s <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee issued I g <br /> 0 Owner Given Reason for Denial <br /> $ 4'7t I 7is fo8 `i.e 4I /�.. v` , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach te complete plans for the system and submit to the County saly an paper not leas than 5 an x I I Inches Ia she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />