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� ioc <br /> 1 • l, C E1WE 11 CJI- <br /> k -� # 010` 3 <br /> LP i { , <br /> ■ ,' ,1," 2 0 2008 <br /> •• commerce.wt.gov Safety and Buildings Division r County <br /> Deriertme. r. <br /> _ 201 W Washington Ave.,P.O.Box 7162 Dane <br /> t /� i'1 C�„ i t (vl D C Madison,WI 53707-7162 Sanitary Permit Number(to be filled m by Co.) <br /> V d� /a7 re, — 517g9(9., <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.13.21(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!nailing 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(IXm),Slats. 1746 Koshkonong Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> James&Erin Milota 0611-132-8000-0 <br /> Property Owner's Mailing Address Property Location <br /> 1746 Koshkonong Road Govt Lot <br /> City,State Zip Code Phone Number NE iv., N W vs section 13 <br /> Stoughton,WI 53589 (circle one) <br /> II.Type of Building(check a0 that apply) ' Lot* T 6 N; R 11 Eon W <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> m <br /> Block P 42 Acre Metes&Bounds <br /> Q public/commercial_Describe Use Home Office <br /> 0 City of <br /> ❑State Owned-Describe Use , CSM Number 0 Village of <br /> Town of Pleasant Springs <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' li New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Pf N1om Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) <br /> at Non-Pressurized In-Ground 0 Pressrrized In-Ground 0 At-Grade 0 Mound>24 in.ofsuitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DisperaaVireatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 152 0.42 218 360 91.5' <br /> VI.Tank Info Capacity in Total *of Manufacturer <br /> Gallons Gallons Units 8 <br /> New Tanks Existing Tanks E g 1 I ij 9 .E it <br /> Septic or Holding Tisk 800 800 1 Crest x • _ <br /> Dosing chamber <br /> VII.Responsibility Statement-I,the undersigned,ass me responiLBity for idstaliatlos of the FOWLS al»wa ou the attached plan. <br /> Plumber's Name(Print) PI Lignatu} MP/M PRS Number Busi ess Phone Number <br /> Thc.Atci5- Rot�J — S-5-2C3 d0 s-2 i5=tSy <br /> Plumber's Address(Street,City, te,Zip Code) <br /> �a I✓1w}7 L4,o,,o( Ra. r)1o" "s 0i. 3'3 7/ <br /> VIII.Coanty/Departmbnt Use Only _ i <br /> �:- pproved ❑Disapproved Permit Fee Date Issued las A ',.r .� , <br /> g.' ♦ �! I r. (7 ,� <br /> 0 Owner Given Reason for Denial s -3'20 512_210 ��/'jo*.I /J.i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attack to template pleas for the system and submit to the Comity only cm paper not men dm s 10 ell!aches la she <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />