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`' _APR 2 2 1:11 <br /> O`leck TO I/005g/ ,D8Tb .2 74-/:'7 <br /> g1 gs Division County <br /> . 201 .,P.O.Box 7162 Dane <br /> I. <br /> ' V �' PUbI l Health son707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> DeParime1't of' ' • nviro tmental Health 5176)(01-1 <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 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,I.15.04(lxm),Stmts. John Deere Lane <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> Mark&Joann Halverson 0712-311-8001-8 <br /> Property Owner's Mailing Address Ptoye,ty Location <br /> 3358 John Deere Lane Go Lot <br /> City,state Zip Code Phone Number NE 'A., NE 'V.,section 31 <br /> Deerfield,WI 53531 T 7 N; R (circle one)W <br /> IL Type of Building(check all that apply) Lot N <br /> ei 1 or 2 Family Dwelling-Number of Bedroom 3 u rvisnon Name <br /> Block 0 33.83 Acre Metes&Bounds <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> Use <br /> ER Town of Deerfield <br /> . ype of Permit (Ch only one box on line A. Complete line B if applicable) <br /> A <br /> ill System Replacement System ❑TrestmenUllokiing Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Trnafer to New Liar Previous Permit Number and Da*lamed <br /> Before Expiration Owner <br /> IV.Type of POWYS System/Component/Device: (Check all that apply) <br /> 13 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Oder Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Di saVfreatment Area Information: <br /> 7 Soilto Design <br /> Application Rate(gpdaf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.5 900 900 94.0`, 95.5' <br /> ark Info Capacity in Total I of Manufacture, <br /> Gallons Gallons Units " u <br /> New Tanb Exisdas Teaks a ,` '' <br /> 6 Al 1 IC7 a <br /> Septic er Holding Took 1250 1250 1 Crest(700/550) x <br /> -timing Chamber ' <br /> VII.Responsibility Statement-I,the andenigaed,assume responsibility for itistalladoa of the POWYS shown on the attached plans. <br /> Plumber's Name(Print) PI a Signature MP/MPRS Number Business Phone Number <br /> <«y \C GI.\ 1 j \ J—( as-4\SS- (6o%) (R3• s- <br /> Plumber's Address(Street,City,Stale,Zip Code) <br /> Code) C q <br /> 30 S .T-a.AOS\-f 6°•\ (s JVOOS�Vh/ -i S 3 r8 4 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing eat Signature <br /> lg%,r <br /> ❑Owner Given Reason for Denial . 4 ^f' , .5 0 _ _ /AII <br /> IX.Conditions of ApproveUReasond for Disapproval <br /> Attach to complete plum ter He system sad submit to the Comity only ea paper not less Mae a tr2 2 11 tueben I.mice <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />