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l � <br /> 14 I JUL 1 4 2008 •- Cite0k _IA) 21;0Ii4 08ry 0.77510 <br /> cornmerce,w,gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Dane <br /> VII f tfra'1;i :T..7-, i! I Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> e� s/811 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.$3.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note•. Application forms for state-owned POWTS are Project Address(if different than mail ng 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,s.15.04(1Xm),Suits. Hannerville Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> Carla Augustine 0511-264-8565-0 <br /> Property Owner's Mailing Address Property Location <br /> 504 Hannerville Road <br /> Govt Lot <br /> City,S t a t e Zip Code Phone Number NW v., S E v., section 26 <br /> Edgerton.WI 53534 873-8295 (circle one) <br /> ---..)II.Type of Building(check all that apply) Lot N T 5 N; R 11 E or W <br /> ®1 or 2 Flintily Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> \\ Block* <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 12486 13 Town of Dunkirk <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> 1 Before Expiration Owner <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 is of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(captain) <br /> V.DlspersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsl) Dispersal Area Required(af) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.5 900 900 96.5° <br /> VI.Tank Info Capacity in Total I of Manufacturer <br /> Galloro Gallons Units a i S 3 .is <br /> New Tanks Existing Tanks 3 <br /> aG r t, v, bT. a <br /> Septic or Holding Tank 1000 1000 1 Dalmaray x <br /> Dosing Camber 600 600 1 Dalmaray x <br /> VII.Responsibility Statement-I,the undersIg assume responsibility f histaliatloa of the POWTS shown on the attached plans. <br /> PI , s Name(Print) I 'a Signature MP/MPRS Number Business Phone Number <br /> ;2,A-, .3.V .� kcR--2� d,a0`Z q 6-- tpc . -713-Zaed <br /> Plumber's A (Street,City,Slate,Zip Code) <br /> VIII.County/Department Use Onl <br /> ,Approved ❑Disapproved Permit Fee Date(sued Issuing Age 4:�'ut/ , / <br /> ❑Owner Given Reason for Denial S 5 /��/O �'/,�,<`/fI <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system sod submit to the Cenary*My on paper not less than a t9 x II Inches is size <br /> SBD-6398(R.01/07)Valid dm 01/09 <br />